Provider Demographics
NPI:1720448921
Name:SALIDA DENTAL HYGIENE PC
Entity Type:Organization
Organization Name:SALIDA DENTAL HYGIENE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:STEIN
Authorized Official - Last Name:WANCURA
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:719-539-2224
Mailing Address - Street 1:124 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2616
Mailing Address - Country:US
Mailing Address - Phone:719-539-2224
Mailing Address - Fax:
Practice Address - Street 1:124 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2616
Practice Address - Country:US
Practice Address - Phone:719-539-2224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOHD200382124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24984531Medicaid