Healthcare Provider Details

I. General information

NPI: 1558016964
Provider Name (Legal Business Name): ESTRELLA VEGA VALENZUELA DA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E COLUMBIA ST
OTHELLO WA
99344-1846
US

IV. Provider business mailing address

1515 E COLUMBIA ST
OTHELLO WA
99344-1846
US

V. Phone/Fax

Practice location:
  • Phone: 509-488-5256
  • Fax: 509-488-9939
Mailing address:
  • Phone: 509-488-5250
  • Fax: 509-488-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD161222067
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: