Provider Demographics
NPI:1154721850
Name:GOVSHIEVICH, MIKHAIL (LD)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:GOVSHIEVICH
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 PARKVIEW DR APT P
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4472
Mailing Address - Country:US
Mailing Address - Phone:503-380-7306
Mailing Address - Fax:
Practice Address - Street 1:9045 SW BARBUR BLVD. SUIT 117
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219
Practice Address - Country:US
Practice Address - Phone:503-380-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTO10154441122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist