Provider Demographics
NPI:1497594014
Name:SERRANO, MARICELLA (LD)
Entity type:Individual
Prefix:
First Name:MARICELLA
Middle Name:
Last Name:SERRANO
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 EAGLE RIDGE DR S UNIT 2
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-3562
Mailing Address - Country:US
Mailing Address - Phone:206-769-6038
Mailing Address - Fax:
Practice Address - Street 1:1609 EAGLE RIDGE DR S UNIT 2
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-3562
Practice Address - Country:US
Practice Address - Phone:206-769-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN61521773122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist