Healthcare Provider Details

I. General information

NPI: 1477993434
Provider Name (Legal Business Name): TATYANA NIKOLAEVNA POLEON L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2013
Last Update Date: 07/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7931 NE HALSEY ST SUITE 307
PORTLAND OR
97213-6755
US

IV. Provider business mailing address

7931 NE HALSEY ST SUITE 307
PORTLAND OR
97213-6755
US

V. Phone/Fax

Practice location:
  • Phone: 360-216-5931
  • Fax: 503-252-1214
Mailing address:
  • Phone: 360-216-5931
  • Fax: 503-252-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-10131109
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: