Basic Information
| Provider Information | |||||||||
| NPI: | 1386160984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRALA | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 78TH AVENUE CT W APT H204 | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984663283 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | OKUBO DENTAL CLINIC 11582 C ST | ||||||||
| Address2: | |||||||||
| City: | JBLM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539661991 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 60757615 | WA | Y | Dental Providers | Dentist |
No ID Information.