Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 121171 | OR |
NPI | 1083102248 |
---|---|
Provider Name | Antonina Kutsar |
First Address | Vancouver, WA 98662-4227 |
Second Address | Portland, OR 97217-5523 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2018 |
Last Update Date | 24/04/2018 |