Healthcare Provider Details

I. General information

NPI: 1083102248
Provider Name (Legal Business Name): ANTONINA KUTSAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 N INTERSTATE AVE
PORTLAND OR
97217-5523
US

IV. Provider business mailing address

8613 NE 97TH CT
VANCOUVER WA
98662-4227
US

V. Phone/Fax

Practice location:
  • Phone: 503-286-6860
  • Fax:
Mailing address:
  • Phone: 360-949-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number121171
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: