Provider Demographics
NPI:1689125122
Name:BACA, TAMARA (RDH MPH)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:RDH MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 E TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-1158
Mailing Address - Country:US
Mailing Address - Phone:602-818-8778
Mailing Address - Fax:
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH04531124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist