Provider Demographics
NPI:1326222142
Name:LINTECUM, JUANITA E (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:E
Last Name:LINTECUM
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:STATE ROAD 75 #15136
Mailing Address - Street 2:P.O. BX 516
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553-0516
Mailing Address - Country:US
Mailing Address - Phone:575-587-2809
Mailing Address - Fax:575-587-2605
Practice Address - Street 1:111 N RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2627
Practice Address - Country:US
Practice Address - Phone:505-753-7218
Practice Address - Fax:505-753-5815
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH2333124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM321831OtherPENASCO DENTAL