Provider Demographics
NPI:1174910822
Name:ECCLES, ELSA (RDH)
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:ECCLES
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 1:900 W ORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1430
Mailing Address - Country:US
Mailing Address - Phone:719-549-3286
Mailing Address - Fax:719-549-3136
Practice Address - Street 1:900 W ORMAN AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1430
Practice Address - Country:US
Practice Address - Phone:719-549-3286
Practice Address - Fax:719-549-3136
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000202004124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist