=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376581587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL VISION PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 934 NE 8TH ST
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-471-7062
-----------------------------------------------------
Fax | 541-471-8539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 934 NE 8TH ST
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-471-7062
-----------------------------------------------------
Fax | 541-471-8539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/PRESIDENT
-----------------------------------------------------
Name | DR. IGOR SHISHKIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 541-471-7062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D6927
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------