Healthcare Provider Details

I. General information

NPI: 1689253817
Provider Name (Legal Business Name): IGOR ALEKSEYEVICH SOTNIKOV RDH EPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 SE 145TH AVE
PORTLAND OR
97236-2671
US

IV. Provider business mailing address

14352 SE LEE AVE
MILWAUKIE OR
97267-1132
US

V. Phone/Fax

Practice location:
  • Phone: 971-242-4396
  • Fax:
Mailing address:
  • Phone: 503-752-4636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7943
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: