Basic Information
| Provider Information | |||||||||
| NPI: | 1003801069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIMANOVSKY | ||||||||
| FirstName: | INNA | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13217 SW ROCKINGHAM DR | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972231779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035211946 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16640 SE MCLOUGHLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | OAK GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972674810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036593003 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/23/2006 | ||||||||
| NPIReactivationDate: | 04/12/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D7792 | OR | Y | Dental Providers | Dentist |
No ID Information.