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Organization
DERRICK BACA DDS LLC
Active
Organization
DERRICK BACA DDS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DERRICK R BACA DDS (GENERAL DENTIST)
(505) 876-4034
Entity
Organization
Contact information
Practice address
1209 BONITA ST, GRANTS, NM 87020-2103
(505) 876-4034
(505) 876-4036
Mailing address
1209 BONITA ST, GRANTS, NM 87020-2103
(505) 876-4034
(505) 876-4036
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DD3492
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
93577389
—
NM
Enumeration date
07/28/2014
Last updated
07/28/2014
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