Provider Demographics
NPI:1013766658
Name:SULAKOV, YANA O
Entity type:Individual
Prefix:
First Name:YANA
Middle Name:O
Last Name:SULAKOV
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 1:11013 NE 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-1578
Mailing Address - Country:US
Mailing Address - Phone:971-998-8146
Mailing Address - Fax:
Practice Address - Street 1:11013 NE 97TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-1578
Practice Address - Country:US
Practice Address - Phone:971-998-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7888124Q00000X
WADH61556024124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist