Healthcare Provider Details

I. General information

NPI: 1184120487
Provider Name (Legal Business Name): MARYNA KOZYRYEV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 08/23/2020
Certification Date: 08/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11670 ATWOOD RD
AUBURN CA
95603-9522
US

IV. Provider business mailing address

7761 APTOS CIR
CITRUS HTS CA
95610-4540
US

V. Phone/Fax

Practice location:
  • Phone: 530-887-2800
  • Fax:
Mailing address:
  • Phone: 916-248-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number104251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: