Healthcare Provider Details

I. General information

NPI: 1043620826
Provider Name (Legal Business Name): ANNA REQUA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24837 104TH AVE SE STE 200
KENT WA
98030-6800
US

IV. Provider business mailing address

24837 104TH AVE SE STE 200
KENT WA
98030-6800
US

V. Phone/Fax

Practice location:
  • Phone: 253-850-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number60801018
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: