Provider Demographics
NPI:1427536341
Name:BRUNETTE, CIERRA LYNN
Entity Type:Individual
Prefix:
First Name:CIERRA
Middle Name:LYNN
Last Name:BRUNETTE
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 1:12402 ADMIRALTY WAY APT I301
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-8583
Mailing Address - Country:US
Mailing Address - Phone:425-299-8240
Mailing Address - Fax:
Practice Address - Street 1:17425 WA-99
Practice Address - Street 2:SUITE D
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037
Practice Address - Country:US
Practice Address - Phone:425-329-7259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD1608177311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAD160817731Medicaid