Basic Information
| Provider Information | |||||||||
| NPI: | 1033878848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUTISTA DE CORDERO | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS,MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE S STE 901 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 LILLY RD NE STE 110 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604568844 | ||||||||
| FaxNumber: | 3608591392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2021 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE61216744 | WA | N | Dental Providers | Dentist | 1223G0001X | DE61216744 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.