Provider Demographics
NPI:1356748784
Name:DMYTRUK, VYACHESLAV (DMD)
Entity type:Individual
Prefix:DR
First Name:VYACHESLAV
Middle Name:
Last Name:DMYTRUK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 W HARVARD AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2795
Mailing Address - Country:US
Mailing Address - Phone:458-802-7028
Mailing Address - Fax:541-516-4345
Practice Address - Street 1:1729 W HARVARD AVE STE 2
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2795
Practice Address - Country:US
Practice Address - Phone:458-802-7028
Practice Address - Fax:541-516-4345
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11399122300000X, 1223G0001X
MEDEN44081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist