Provider Demographics
NPI:1881075182
Name:PERRYMAN, THALIA-RAE (DMD)
Entity type:Individual
Prefix:
First Name:THALIA-RAE
Middle Name:
Last Name:PERRYMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 SE 192ND AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-6505
Mailing Address - Country:US
Mailing Address - Phone:360-835-6001
Mailing Address - Fax:
Practice Address - Street 1:1625 SE 192ND AVE # 205
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7441
Practice Address - Country:US
Practice Address - Phone:360-835-6001
Practice Address - Fax:360-835-6002
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11463122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist