Provider Demographics
NPI:1235294091
Name:BACA, CHRISTIE ANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTIE
Middle Name:ANN
Last Name:BACA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4047
Mailing Address - Country:US
Mailing Address - Phone:505-454-8483
Mailing Address - Fax:505-454-8767
Practice Address - Street 1:925 MILLS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4047
Practice Address - Country:US
Practice Address - Phone:505-454-8483
Practice Address - Fax:505-454-8767
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH1103124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist