Provider Demographics
NPI:1457774168
Name:IGNACIO DENTAL HYGIENE
Entity Type:Organization
Organization Name:IGNACIO DENTAL HYGIENE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ENA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MILLICH
Authorized Official - Suffix:
Authorized Official - Credentials:RD H
Authorized Official - Phone:970-563-0373
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0785
Mailing Address - Country:US
Mailing Address - Phone:970-563-0373
Mailing Address - Fax:970-563-9037
Practice Address - Street 1:610 GODDARD
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-0785
Practice Address - Country:US
Practice Address - Phone:970-563-0373
Practice Address - Fax:970-563-9037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
CO2023390302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========Medicaid