Provider Demographics
NPI:1730607961
Name:BACKUS, TERRY MONICA (RDH)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:MONICA
Last Name:BACKUS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 415 BOX 5381
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09114-0054
Mailing Address - Country:US
Mailing Address - Phone:015-174-3412
Mailing Address - Fax:
Practice Address - Street 1:GRAFEWOHR DENTAL CLINIC
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:314-477-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3403124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist