Provider Demographics
NPI:1942559596
Name:POLIASHOV, MARINA V (RDH)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:V
Last Name:POLIASHOV
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 1:16038 SE NEHALEM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-5387
Mailing Address - Country:US
Mailing Address - Phone:503-473-7778
Mailing Address - Fax:
Practice Address - Street 1:10102 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-238-4418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR117669126800000X
ORH7006124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH7006OtherOREGON BOARD OF DENTISTRY