Provider Demographics
NPI:1275615346
Name:WANCURA, MARIANNE (RDH)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:WANCURA
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 1:124 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2616
Mailing Address - Country:US
Mailing Address - Phone:719-539-2224
Mailing Address - Fax:
Practice Address - Street 1:124 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2616
Practice Address - Country:US
Practice Address - Phone:719-539-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOHD200382124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOTP123536AOtherTRADING PARTNER ID
CO24984531Medicaid