Provider Demographics
NPI:1578965356
Name:BACA, ERMELINDA
Entity Type:Individual
Prefix:
First Name:ERMELINDA
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-7429
Mailing Address - Country:US
Mailing Address - Phone:505-864-6969
Mailing Address - Fax:505-864-9310
Practice Address - Street 1:1501 E RIVER RD
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-7429
Practice Address - Country:US
Practice Address - Phone:505-864-6969
Practice Address - Fax:505-864-9310
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH363124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist