Provider Demographics
NPI:1710323209
Name:JASINA, OLGA
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:JASINA
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 1:1640 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1856
Mailing Address - Country:US
Mailing Address - Phone:214-680-0443
Mailing Address - Fax:719-362-4227
Practice Address - Street 1:1640 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1856
Practice Address - Country:US
Practice Address - Phone:214-680-0443
Practice Address - Fax:719-362-4227
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-11
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039464122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist