Provider Demographics
NPI:1194300624
Name:DOVZHENKO, ANASTASIYA
Entity type:Individual
Prefix:
First Name:ANASTASIYA
Middle Name:
Last Name:DOVZHENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST, HSB ROOM B 241
Mailing Address - Street 2:BOX 357134
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195
Mailing Address - Country:US
Mailing Address - Phone:206-543-7496
Mailing Address - Fax:
Practice Address - Street 1:5089 W 12600 S
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-2598
Practice Address - Country:US
Practice Address - Phone:801-748-0379
Practice Address - Fax:801-304-3151
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12833513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program