=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962920090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IZABELLA PIKULA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 09/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 3RD ST SE STE 104
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-697-0201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9415 163RD STREET CT E
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98375-6212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-259-1135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------