Basic Information
| Provider Information | |||||||||
| NPI: | 1700518925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALCIDO | ||||||||
| FirstName: | JANTIL | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 128 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195871001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 421 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | LA JARA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811405064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192748948 | ||||||||
| FaxNumber: | 7192748920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2022 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2026503 | CO | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 2026503 | 01 | CO | LICENSE NUMBER | OTHER |