Provider Demographics
NPI:1134615735
Name:PUGACZEWSKI, RONDA MECHELLE
Entity type:Individual
Prefix:MRS
First Name:RONDA
Middle Name:MECHELLE
Last Name:PUGACZEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RONDA
Other - Middle Name:MECHELLE
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12621 164TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9523
Mailing Address - Country:US
Mailing Address - Phone:253-445-6782
Mailing Address - Fax:
Practice Address - Street 1:12621 164TH ST E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-9523
Practice Address - Country:US
Practice Address - Phone:253-445-6782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant