EFTA00520949.pdf

Dental Board of California Remove your new Pocket License from the receipt portion and carry 2005 Evergreen Street, Suite 1550 it with you at all times. Sacramento, CA 95815.3831 (Please cut along the dotted lines) Dental Board of California IMPORTANT 2005 Evergreen Street. Suite 1550 Sacramento. CA 95815.3831 1. Please include your license number on any (916)263-2300 correspondence to this office. cica Toll Free (877)729-7789 2. Notify the Board of any name or address change in writing. DENTIST License No. Expiration 3. Report any loss immediately in writing to the Board. Inactive 05/31/2021 4. Please sign and carry the pocket license with you. KARYNA SHULIAK Original Issue Date License No. Expiration Date Receipt No. 6100 RED HOOK QTRS SUITE B-3 11/19/2015 05/31/2021 63140 ST THOMAS, VI 00802-1348 KARYNA SHULIAK Receipt No. Signature 63140 This is your RECEIPT. Please save for your records. MOOS 05/2016 8 I gs id Id 94E1.20900 in SVIAIOH.L .LS El) 3ins 98.10 )1001103/J001.9 vents VNA2:0O1 9S6 OCIW 03XIVV..0111V kill 9 L 996 VO OIN3NPILIOVS 099 L N338O2A3A3 S003 VINLIOAI1VO AO O8VO9 WINK] EFTA00520949