Provider Demographics
NPI:1053956573
Name:CHERNISHOV, FROSINA
Entity type:Individual
Prefix:
First Name:FROSINA
Middle Name:
Last Name:CHERNISHOV
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 1:822 PANA ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-5585
Mailing Address - Country:US
Mailing Address - Phone:503-951-9321
Mailing Address - Fax:
Practice Address - Street 1:822 PANA ST
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-5585
Practice Address - Country:US
Practice Address - Phone:503-951-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7847124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist