Individual
FAHRA MERCHANT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
10518 S TACOMA WAY STE B, TACOMA, WA 98499-5400
(253) 584-8840
Mailing address
14217 SE 83RD ST, NEWCASTLE, WA 98059-3456
(253) 584-8840
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DE00009481
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5041355
—
WA
Enumeration date
01/23/2007
Last updated
07/09/2007
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