Provider Demographics
NPI:1801234489
Name:GILLETTE-BACKSTROM, JANICA JOLI (RDH, DDS)
Entity type:Individual
Prefix:DR
First Name:JANICA
Middle Name:JOLI
Last Name:GILLETTE-BACKSTROM
Suffix:
Gender:F
Credentials:RDH, DDS
Other - Prefix:DR
Other - First Name:JANICA
Other - Middle Name:J
Other - Last Name:GILLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH, DDS
Mailing Address - Street 1:4680 STONE MANOR HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8605
Mailing Address - Country:US
Mailing Address - Phone:208-251-9803
Mailing Address - Fax:
Practice Address - Street 1:6940 MESA RIDGE PARKWAY
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817
Practice Address - Country:US
Practice Address - Phone:719-382-4936
Practice Address - Fax:719-382-4938
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-44941223G0001X
CODEN.002027041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice