Healthcare Provider Details

I. General information

NPI: 1902006828
Provider Name (Legal Business Name): DANAE TULLOCH RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 WESTGATE BLVD
TACOMA WA
98406
US

IV. Provider business mailing address

PO BOX 994
TACOMA WA
98401-0994
US

V. Phone/Fax

Practice location:
  • Phone: 253-301-9911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH5856
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: