Provider Demographics
NPI:1902349442
Name:ZAKHAROVA, EKATERINA
Entity Type:Individual
Prefix:
First Name:EKATERINA
Middle Name:
Last Name:ZAKHAROVA
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 1:4918 1/2 MCCONNELL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE
Practice Address - Street 2:ORTHODONTICS DEPARTMENT
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:612-625-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1020241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics