Healthcare Provider Details

I. General information

NPI: 1700206950
Provider Name (Legal Business Name): OLGA I ZLATOVA I RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 04/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SE 154TH AVE
PORTLAND OR
97233
US

IV. Provider business mailing address

325 SE 154TH AVE
PORTLAND OR
97233-3107
US

V. Phone/Fax

Practice location:
  • Phone: 503-730-2782
  • Fax:
Mailing address:
  • Phone: 503-730-2782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH6614
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: