Provider Demographics
NPI:1679440044
Name:BACA, KATHY LESLIE (RDH)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:LESLIE
Last Name:BACA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99B STATE ROAD 73
Mailing Address - Street 2:
Mailing Address - City:VADITO
Mailing Address - State:NM
Mailing Address - Zip Code:87579-9000
Mailing Address - Country:US
Mailing Address - Phone:575-251-8010
Mailing Address - Fax:505-575-2426
Practice Address - Street 1:201 K 2 BUFFALO TRAIL
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:575-251-8010
Practice Address - Fax:575-242-6214
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH4492124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty