Healthcare Provider Details

I. General information

NPI: 1780306316
Provider Name (Legal Business Name): COLTILDA ETCITTY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAGEBRUSH ST SW
ALBUQUERQUE NM
87105-3942
US

IV. Provider business mailing address

1 SAGEBRUSH ST SW
ALBUQUERQUE NM
87105-3942
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-3200
  • Fax: 505-869-4584
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH5370
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: