Provider Demographics
NPI:1477993434
Name:POLEON, TATYANA NIKOLAEVNA (LD)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:NIKOLAEVNA
Last Name:POLEON
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7931 NE HALSEY ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6755
Mailing Address - Country:US
Mailing Address - Phone:360-216-5931
Mailing Address - Fax:503-252-1214
Practice Address - Street 1:7931 NE HALSEY ST
Practice Address - Street 2:SUITE 307
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-6755
Practice Address - Country:US
Practice Address - Phone:360-216-5931
Practice Address - Fax:503-252-1214
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-04
Last Update Date:2013-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10131109122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist