Jacqueline Nichole Sanders, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DENT.DE.61321157 Issued in WA

Practice address

412 Bowes Dr
Fircrest, WA 98466-7057

Phone

(219) 256-2472

NPI assigned

Jul 14, 2022

Last updated

Jul 26, 2023By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Jacqueline Nichole Petrovich Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1657756800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1690329600000",
    "number": "1750015780",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1215 83RD ST E",
            "city": "TACOMA",
            "state": "WA",
            "postal_code": "984043340"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "412 BOWES DR",
            "city": "FIRCREST",
            "state": "WA",
            "postal_code": "984667057",
            "telephone_number": "219-256-2472"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SANDERS",
        "first_name": "JACQUELINE",
        "middle_name": "NICHOLE",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-07-14",
        "last_updated": "2023-07-26",
        "certification_date": "2023-07-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WA",
            "license": "61321157",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DENT.DE.61321157",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACQUELINE",
            "last_name": "PETROVICH",
            "middle_name": "NICHOLE",
            "credential": "DDS",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• General Practice Dentistry in Fircrest, WA
• Providers in Fircrest, WA by specialty
• General Practice Dentistry in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.