Provider Demographics
NPI:1174989339
Name:SELLS, TACY LYN I (RDA)
Entity type:Individual
Prefix:
First Name:TACY
Middle Name:LYN
Last Name:SELLS
Suffix:I
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 WOODS PL
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-7128
Mailing Address - Country:US
Mailing Address - Phone:206-326-0611
Mailing Address - Fax:
Practice Address - Street 1:17425 HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-3101
Practice Address - Country:US
Practice Address - Phone:425-409-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD1 60052961126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant