Provider Demographics
NPI:1114466620
Name:SHULIK, MALVINA (RDH)
Entity Type:Individual
Prefix:
First Name:MALVINA
Middle Name:
Last Name:SHULIK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:MARIYA
Other - Middle Name:
Other - Last Name:GORELOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16415 NE FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5056
Mailing Address - Country:US
Mailing Address - Phone:503-784-3265
Mailing Address - Fax:
Practice Address - Street 1:10102 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4456
Practice Address - Country:US
Practice Address - Phone:503-286-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6063124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist