Provider Demographics
NPI:1679026595
Name:DALINE, IRYNA HRYVENKO
Entity Type:Individual
Prefix:
First Name:IRYNA
Middle Name:HRYVENKO
Last Name:DALINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRYNA
Other - Middle Name:
Other - Last Name:HRYVENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11009 ALTERRA PKWY APT 1719
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-1309
Mailing Address - Country:US
Mailing Address - Phone:612-458-4781
Mailing Address - Fax:612-626-0138
Practice Address - Street 1:1920 E RIVERSIDE DR STE A-140
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-1351
Practice Address - Country:US
Practice Address - Phone:512-640-8747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418170122300000X
TX39193122300000X, 1223X2210X, 1223E0200X
MNR665122300000X
MNS1521223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
No1223X2210XDental ProvidersDentistOrofacial Pain