Provider Demographics
NPI:1205249141
Name:ANSERELLO, SONICA NATISSIA (RDH)
Entity type:Individual
Prefix:
First Name:SONICA
Middle Name:NATISSIA
Last Name:ANSERELLO
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 1:1708 E 44TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-4611
Mailing Address - Country:US
Mailing Address - Phone:253-572-7002
Mailing Address - Fax:253-593-2854
Practice Address - Street 1:1708 E 44TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4611
Practice Address - Country:US
Practice Address - Phone:253-572-7002
Practice Address - Fax:253-593-2854
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60240421124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist