Provider Demographics
NPI:1073735791
Name:AZCUETA, RUBY
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:AZCUETA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 SE 17TH CT
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-3804
Mailing Address - Country:US
Mailing Address - Phone:206-919-5938
Mailing Address - Fax:206-725-3838
Practice Address - Street 1:5425 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-2455
Practice Address - Country:US
Practice Address - Phone:206-725-3667
Practice Address - Fax:206-725-3838
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00005699124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist