Provider Demographics
NPI:1992315998
Name:PROSOLUPOVA, TATYANA
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:PROSOLUPOVA
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 1:518 11TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4296
Mailing Address - Country:US
Mailing Address - Phone:213-239-4181
Mailing Address - Fax:
Practice Address - Street 1:1431 W KNOX ST STE 800
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-1358
Practice Address - Country:US
Practice Address - Phone:310-320-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1051661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice