Provider Demographics
NPI:1780034587
Name:GRAND MESA DENTAL HYGIENE, LLC
Entity Type:Organization
Organization Name:GRAND MESA DENTAL HYGIENE, LLC
Other - Org Name:GRAND MESA DENTAL HYGIENE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:VIGIL
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:970-874-3801
Mailing Address - Street 1:417 MEEKER ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-1918
Mailing Address - Country:US
Mailing Address - Phone:970-874-3801
Mailing Address - Fax:970-874-3807
Practice Address - Street 1:417 MEEKER ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-1918
Practice Address - Country:US
Practice Address - Phone:970-874-3801
Practice Address - Fax:970-874-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904294124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49732048Medicaid