Provider Demographics
NPI:1558620971
Name:MANUYLOV, OLGA A
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:A
Last Name:MANUYLOV
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 1:1144 49TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-0862
Mailing Address - Country:US
Mailing Address - Phone:503-881-4341
Mailing Address - Fax:
Practice Address - Street 1:2300 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1223
Practice Address - Country:US
Practice Address - Phone:503-370-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant