Basic Information
| Provider Information | |||||||||
| NPI: | 1669142683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAURENTE | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | NICOLE CRUZ | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1089 LAKE WASHINGTON BLVD N APT A304 | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980566467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034759523 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 164 SW CAMPUS DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980237926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534328942 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2021 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DENT.DE.61200714 | WA | Y | Dental Providers | Dentist |
No ID Information.