Provider Demographics
NPI:1750015780
Name:SANDERS, JACQUELINE NICHOLE (DDS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICHOLE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NICHOLE
Other - Last Name:PETROVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1215 83RD ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-3340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 BOWES DR
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-7057
Practice Address - Country:US
Practice Address - Phone:219-256-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61321157122300000X
WADENT.DE.613211571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist