Provider Demographics
NPI:1376618025
Name:VIGIL, MARY POWELL (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:POWELL
Last Name:VIGIL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:VIGIL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:494 HIGHWAY 92
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-3441
Mailing Address - Country:US
Mailing Address - Phone:970-874-3801
Mailing Address - Fax:970-874-3807
Practice Address - Street 1:494 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-3441
Practice Address - Country:US
Practice Address - Phone:970-874-3801
Practice Address - Fax:970-874-3807
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904294124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49732048Medicaid