Provider Demographics
NPI:1184120487
Name:KOZYRYEV, MARYNA
Entity type:Individual
Prefix:
First Name:MARYNA
Middle Name:
Last Name:KOZYRYEV
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 1:7761 APTOS CIR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-4540
Mailing Address - Country:US
Mailing Address - Phone:916-248-6961
Mailing Address - Fax:
Practice Address - Street 1:11670 ATWOOD RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9522
Practice Address - Country:US
Practice Address - Phone:530-887-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist