Healthcare Provider Details

I. General information

NPI: 1568708014
Provider Name (Legal Business Name): LYNETTE EILENE BACKMAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNETTE EILENE JENNINGS RDH

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 COCHRANE CIR BLDG 7495
FORT CARSON CO
80913-4603
US

IV. Provider business mailing address

1667 COCHRANE CIR BLDG 7495
FORT CARSON CO
80913-4603
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-5537
  • Fax:
Mailing address:
  • Phone: 719-526-5537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH 12389
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2242
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.000906518
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: