Provider Demographics
NPI:1235643115
Name:VERSHININA, GOAR
Entity Type:Individual
Prefix:
First Name:GOAR
Middle Name:
Last Name:VERSHININA
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 1:1421 AMBASSADOR ST APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2834
Mailing Address - Country:US
Mailing Address - Phone:818-585-8023
Mailing Address - Fax:
Practice Address - Street 1:416 N BEDFORD DR STE 103
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4308
Practice Address - Country:US
Practice Address - Phone:818-585-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist