Healthcare Provider Details

I. General information

NPI: 1205249141
Provider Name (Legal Business Name): SONICA NATISSIA ANSERELLO RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 E 44TH ST
TACOMA WA
98404-4611
US

IV. Provider business mailing address

1708 E 44TH ST
TACOMA WA
98404-4611
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-7002
  • Fax: 253-593-2854
Mailing address:
  • Phone: 253-572-7002
  • Fax: 253-593-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH60240421
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: