Healthcare Provider Details

I. General information

NPI: 1609455963
Provider Name (Legal Business Name): PATRICIA L FLYNN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LEWIS ST # 3D
PAGOSA SPRINGS CO
81147-7508
US

IV. Provider business mailing address

417 FINCH DR
PAGOSA SPRINGS CO
81147-7868
US

V. Phone/Fax

Practice location:
  • Phone: 970-382-1972
  • Fax:
Mailing address:
  • Phone: 970-382-1972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH000905012
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: