Provider Demographics
NPI:1003801069
Name:SHIMANOVSKY, INNA V (DMD)
Entity Type:Individual
Prefix:DR
First Name:INNA
Middle Name:V
Last Name:SHIMANOVSKY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13217 SW ROCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1779
Mailing Address - Country:US
Mailing Address - Phone:503-521-1946
Mailing Address - Fax:
Practice Address - Street 1:16640 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:OR
Practice Address - Zip Code:97267-4810
Practice Address - Country:US
Practice Address - Phone:503-659-3003
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
ORD7792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist