Basic Information
| Provider Information | |||||||||
| NPI: | 1730791815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYSNYK | ||||||||
| FirstName: | IRYNA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10928 TRINITY PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952197230 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10928 TRINITY PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952197230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094748000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 105301 | CA | Y | Dental Providers | Dentist |
No ID Information.