Healthcare Provider Details

I. General information

NPI: 1457848046
Provider Name (Legal Business Name): MYRA ALEJANDRA GAUCIN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5995 IRIS PKWY
FREDERICK CO
80504-6412
US

IV. Provider business mailing address

5995 IRIS PKWY
FREDERICK CO
80504-6412
US

V. Phone/Fax

Practice location:
  • Phone: 909-531-8529
  • Fax:
Mailing address:
  • Phone: 303-697-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.002024768
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: