1558686998 NPI number — YELENA GOLOBORODKO B.S., R.D.H.

Table of content: YELENA GOLOBORODKO B.S., R.D.H. (NPI 1558686998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558686998 NPI number — YELENA GOLOBORODKO B.S., R.D.H.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLOBORODKO
Provider First Name:
YELENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.S., R.D.H.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLOBORODKO
Provider Other First Name:
ALYONA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1558686998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 SW OAK ST
Provider Second Line Business Mailing Address:
STE.210
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97204-1817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-988-7468
Provider Business Mailing Address Fax Number:
503-988-3015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NE 8TH ST FL 3
Provider Second Line Business Practice Location Address:
DENTAL CLINIC
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-7317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-988-4900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  H5346 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)