Provider Demographics
NPI:1750931077
Name:SOPER, CHANNA (RDH)
Entity type:Individual
Prefix:
First Name:CHANNA
Middle Name:
Last Name:SOPER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:CHANNA
Other - Middle Name:
Other - Last Name:HEROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:798 WEST RD
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-9543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:798 WEST RD
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-9543
Practice Address - Country:US
Practice Address - Phone:512-417-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13311124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist