Healthcare Provider Details

I. General information

NPI: 1972917607
Provider Name (Legal Business Name): MARIA DE LA CERDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3602 6TH AVE STE 104
TACOMA WA
98406-5450
US

IV. Provider business mailing address

3602 6TH AVE STE 104
TACOMA WA
98406-5450
US

V. Phone/Fax

Practice location:
  • Phone: 253-777-4461
  • Fax: 253-752-0220
Mailing address:
  • Phone: 253-777-4461
  • Fax: 253-752-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD1 60465005
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: