Provider Demographics
NPI:1467027722
Name:VARGAS SOTO, BLANCA IBETH (RDH)
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:IBETH
Last Name:VARGAS SOTO
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 1:4562 W SELDON LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-5244
Mailing Address - Country:US
Mailing Address - Phone:602-748-0248
Mailing Address - Fax:
Practice Address - Street 1:4562 W SELDON LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5244
Practice Address - Country:US
Practice Address - Phone:602-748-0248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH008467124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86-0498020Medicaid