Provider Demographics
NPI:1891788246
Name:BACA, PAMELA M (DDS)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:M
Last Name:BACA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:M
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:111 N RAILROAD AVE
Mailing Address - Street 2:P.O. BOX 158
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2627
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:3031 HOT SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4120
Practice Address - Country:US
Practice Address - Phone:505-425-6677
Practice Address - Fax:505-425-9638
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD17191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80044Medicaid
NM9177330OtherDORAL