Individual
LEROY BACA
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1960 N DATE ST, T OR C, NM 87901-3701
(505) 267-3088
(505) 267-1747
Mailing address
255 HWY 187, P.O BOX 370, HATCH, NM 87937-0370
(505) 267-3088
(505) 267-1747
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DD1705
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
88079
—
NM
Enumeration date
08/24/2005
Last updated
07/08/2007
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