Provider Demographics
NPI:1033890835
Name:BULAON, NICOLETTE ANN HECITA (DMD)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:ANN HECITA
Last Name:BULAON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23240 88TH AVE S APT R203
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4481
Mailing Address - Country:US
Mailing Address - Phone:206-201-4649
Mailing Address - Fax:
Practice Address - Street 1:16810 MERIDIAN E STE J107
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-9604
Practice Address - Country:US
Practice Address - Phone:253-848-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61449731122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice