Healthcare Provider Details

I. General information

NPI: 1356780167
Provider Name (Legal Business Name): RITA SEBASTIANA OHRDORF BSRDH MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RITA SEBASTIANA PALMERI

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 6TH ST STE V
PUEBLO CO
81003-2378
US

IV. Provider business mailing address

1000 W 6TH ST STE V
PUEBLO CO
81003-2378
US

V. Phone/Fax

Practice location:
  • Phone: 719-542-7420
  • Fax:
Mailing address:
  • Phone: 719-542-7420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number000003069
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: