EFTA00524025.pdf

Application Summary 3/26/19 11:30 AM Page 1 of 1 License Type: Dentist License Number: File Number: 51564 Application: Change of Address Application Number: 6822987 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. Effective Date of Address Change Effective Date: 03/26/2019 (mm/dd/yyyy) Attachments Attestation I certify under the penalty of perjury, under the law of the State of California that the information in this application and any attachments are true and correct. Signature: Date: 1553675054294 EFTA00524025