Provider Demographics
NPI:1174922231
Name:BACA-SALAZAR, ALICIA (RDH)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BACA-SALAZAR
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 1:10700 STONE HOLLOW PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3797
Mailing Address - Country:US
Mailing Address - Phone:505-280-2322
Mailing Address - Fax:
Practice Address - Street 1:4405 JAGER DR NE STE C1
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-5715
Practice Address - Country:US
Practice Address - Phone:505-867-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH2180124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist