Provider Demographics
NPI:1346895869
Name:BERMUDEZ, STACI A (RDH)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:A
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3377 BETHEL RD SE # 107-155
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5608
Mailing Address - Country:US
Mailing Address - Phone:360-602-9493
Mailing Address - Fax:206-745-3811
Practice Address - Street 1:2235 NE CASTLE DR
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8068
Practice Address - Country:US
Practice Address - Phone:206-745-3808
Practice Address - Fax:206-745-3811
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHL60609954124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist