Healthcare Provider Details

I. General information

NPI: 1073735791
Provider Name (Legal Business Name): RUBY AZCUETA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 RAINIER AVE S
SEATTLE WA
98118-2455
US

IV. Provider business mailing address

3120 SE 17TH CT
RENTON WA
98058-3804
US

V. Phone/Fax

Practice location:
  • Phone: 206-725-3667
  • Fax: 206-725-3838
Mailing address:
  • Phone: 206-919-5938
  • Fax: 206-725-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH00005699
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: