Provider Demographics
NPI:1720469240
Name:KORNUTA, TANYA (RDH)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:KORNUTA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21919 NE HEARTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-6790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16755 SW BASELINE RD
Practice Address - Street 2:106
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-533-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6746124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist