Healthcare Provider Details

I. General information

NPI: 1609025881
Provider Name (Legal Business Name): ELAINE T MONCIBAIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E RAILROAD AVE
FORT MORGAN CO
80701-3340
US

IV. Provider business mailing address

203 S ROLLIE AVE
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 970-867-0300
  • Fax: 970-867-7607
Mailing address:
  • Phone: 303-286-4560
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number904120
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: