EFTA00524024.pdf

Application Summary 3/26/19 11:26 AM Page 1 of 1 License Type: Dentist License Number: File Number: 51564 Application: Change Status to Inactive Application Number: 6822985 Application Date: 03/26/2019 (mm/dd/yyyy) Personal Detail First Name: KARYNA Last Name: SHULIAK Addresses License Related Addresses Address of Record Warning: In order to protect your privacy and identity, address will not be displayed. Confidential Address Warning: In order to protect your privacy and identity, address will not be displayed. Attachments Attestation I certify under the penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct. Signature: Date: 1553674801737 EFTA00524024