Healthcare Provider Details

I. General information

NPI: 1376618025
Provider Name (Legal Business Name): MARY POWELL VIGIL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY VIGIL RDH

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 HIGHWAY 92
DELTA CO
81416-3441
US

IV. Provider business mailing address

494 HIGHWAY 92
DELTA CO
81416-3441
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-3801
  • Fax: 970-874-3807
Mailing address:
  • Phone: 970-874-3801
  • Fax: 970-874-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number904294
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: