Healthcare Provider Details

I. General information

NPI: 1932265923
Provider Name (Legal Business Name): IRINA OLMEZOVA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 ALCATRAZ AVENUE
BERKELEY CA
94703
US

IV. Provider business mailing address

1860 ALCATRAZ AVE
BERKELEY CA
94703-2715
US

V. Phone/Fax

Practice location:
  • Phone: 510-653-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number49036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: