Healthcare Provider Details

I. General information

NPI: 1679440044
Provider Name (Legal Business Name): KATHY LESLIE BACA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/21/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 K 2 BUFFALO TRAIL
PENASCO NM
87553
US

IV. Provider business mailing address

99B STATE ROAD 73
VADITO NM
87579-9000
US

V. Phone/Fax

Practice location:
  • Phone: 575-251-8010
  • Fax: 575-242-6214
Mailing address:
  • Phone: 575-251-8010
  • Fax: 505-575-2426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH4492
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: