Provider Demographics
NPI:1578924056
Name:BAHRE, STACEY (RDH, BS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BAHRE
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 LINDEN STREET
Mailing Address - Street 2:SUITE #2
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80538
Mailing Address - Country:US
Mailing Address - Phone:303-772-2392
Mailing Address - Fax:
Practice Address - Street 1:1332 LINDEN ST
Practice Address - Street 2:SUITE #2
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3257
Practice Address - Country:US
Practice Address - Phone:303-772-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002023982124Q00000X
SDDH1223124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist