=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346895869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACI A BERMUDEZ RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2019
-----------------------------------------------------
Last Update Date | 08/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2235 NE CASTLE DR
-----------------------------------------------------
City | POULSBO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98370-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-745-3808
-----------------------------------------------------
Fax | 206-745-3811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3377 BETHEL RD SE # 107-155
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-602-9493
-----------------------------------------------------
Fax | 206-745-3811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | HL60609954
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------