Healthcare Provider Details

I. General information

NPI: 1902214406
Provider Name (Legal Business Name): DERRICK BACA DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 BONITA ST
GRANTS NM
87020-2103
US

IV. Provider business mailing address

1209 BONITA ST
GRANTS NM
87020-2103
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-4034
  • Fax: 505-876-4036
Mailing address:
  • Phone: 505-876-4034
  • Fax: 505-876-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3492
License Number StateNM

VIII. Authorized Official

Name: DR. DERRICK R BACA
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 505-876-4034