Healthcare Provider Details

I. General information

NPI: 1174910822
Provider Name (Legal Business Name): ELSA ECCLES RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W ORMAN AVE
PUEBLO CO
81004-1430
US

IV. Provider business mailing address

900 W ORMAN AVE
PUEBLO CO
81004-1430
US

V. Phone/Fax

Practice location:
  • Phone: 719-549-3286
  • Fax: 719-549-3136
Mailing address:
  • Phone: 719-549-3286
  • Fax: 719-549-3136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number000202004
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: