Healthcare Provider Details

I. General information

NPI: 1457774168
Provider Name (Legal Business Name): IGNACIO DENTAL HYGIENE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 GODDARD
IGNACIO CO
81137-0785
US

IV. Provider business mailing address

PO BOX 785
IGNACIO CO
81137-0785
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-0373
  • Fax: 970-563-9037
Mailing address:
  • Phone: 970-563-0373
  • Fax: 970-563-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2023390
License Number StateCO

VIII. Authorized Official

Name: MISS ENA MARIE MILLICH
Title or Position: OWNER
Credential: R.D. H.
Phone: 970-563-0373