Provider Demographics
NPI:1447561956
Name:KHUSHENAZAROVA, LARISA (RDH)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:KHUSHENAZAROVA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 415 BOX 6915
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09114-0070
Mailing Address - Country:US
Mailing Address - Phone:01522-332-7677
Mailing Address - Fax:
Practice Address - Street 1:GRAFENWOEHR DENTAL CLINIC
Practice Address - Street 2:UNIT 28130
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:964-183-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021313124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist