Provider Demographics
NPI:1861135568
Name:PARKHOMENKO, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:PARKHOMENKO
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 1:530 S WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1213
Mailing Address - Country:US
Mailing Address - Phone:801-587-2162
Mailing Address - Fax:
Practice Address - Street 1:1585 MALLORY LN STE 101
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3036
Practice Address - Country:US
Practice Address - Phone:615-377-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN121611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice