Provider Demographics
NPI:1215325162
Name:MILLICH, ENA MARIE (RDH)
Entity type:Individual
Prefix:
First Name:ENA
Middle Name:MARIE
Last Name:MILLICH
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:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0785
Mailing Address - Country:US
Mailing Address - Phone:970-563-0373
Mailing Address - Fax:
Practice Address - Street 1:610 GODDARD AVE.
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-0785
Practice Address - Country:US
Practice Address - Phone:970-563-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2023390124Q00000X
COCO2023390124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist