Healthcare Provider Details

I. General information

NPI: 1679442669
Provider Name (Legal Business Name): AMANDA JO BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 10/30/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E SANTA FE
GRANTS NM
87020-3926
US

IV. Provider business mailing address

1611 TERRACE LOOP
GRANTS NM
87020-3926
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-6046
  • Fax:
Mailing address:
  • Phone: 505-350-6046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2920
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: