Provider Demographics
NPI:1811660160
Name:BACA, WENDY MICHAELENE (RDH)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:MICHAELENE
Last Name:BACA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:MICHAELENE
Other - Last Name:BACHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:PO BOX 3334
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:NM
Mailing Address - Zip Code:87021-3334
Mailing Address - Country:US
Mailing Address - Phone:505-290-1174
Mailing Address - Fax:
Practice Address - Street 1:1105 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1189
Practice Address - Country:US
Practice Address - Phone:575-746-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH1303124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist