Healthcare Provider Details

I. General information

NPI: 1578965356
Provider Name (Legal Business Name): ERMELINDA BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E RIVER RD
BELEN NM
87002-7429
US

IV. Provider business mailing address

1501 E RIVER RD
BELEN NM
87002-7429
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-6969
  • Fax: 505-864-9310
Mailing address:
  • Phone: 505-864-6969
  • Fax: 505-864-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH363
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: