Basic Information
Provider Information | |||||||||
NPI: | 1881644235 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VALDEZ DETELLO | ||||||||
FirstName: | EDITH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VALDEZ | ||||||||
OtherFirstName: | EDIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RDH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 23508 E OHAWA PL | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | CO | ||||||||
PostalCode: | 80016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033079076 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1055 CLERMONT ST | ||||||||
Address2: | DENTAL 160 DEPT OF VETERANS AFFAIRS ECHCS | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 80220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033932823 | ||||||||
FaxNumber: | 3033934632 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 3013 | CO | Y |   | Dental Providers | Dental Hygienist |   |
ID Information
ID | Type | State | Issuer | Description | 06000008 | 01 | CO | VA | OTHER |