Healthcare Provider Details

I. General information

NPI: 1720710098
Provider Name (Legal Business Name): HALEY MARIE SANDERS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N 6TH ST
CANON CITY CO
81212-3329
US

IV. Provider business mailing address

128 MARKET ST
ALAMOSA CO
81101-2290
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-2301
  • Fax: 719-275-4131
Mailing address:
  • Phone: 719-587-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2026499
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: