Healthcare Provider Details

I. General information

NPI: 1467715631
Provider Name (Legal Business Name): SVETLANA DOVGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 NW BURNSIDE RD
GRESHAM OR
97030-3852
US

IV. Provider business mailing address

360 NW BURNSIDE RD
GRESHAM OR
97030-3852
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-7480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number118216
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: