Basic Information
| Provider Information | |||||||||
| NPI: | 1154824100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUOFF | ||||||||
| FirstName: | PENELOPE | ||||||||
| MiddleName: | PHUONG MINH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9307 NE 118TH LN APT 2-201 | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343632 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16549 AURORA AVE N | ||||||||
| Address2: | |||||||||
| City: | SHORELINE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981335308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065332600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2018 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60864449 | WA | Y | Dental Providers | Dentist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.