Application Summary 3/26/19 11:30 AM License Type: License Number: File Number: Application: Application Number: Application Date: Dentist 51564 Change of Address 6822987 03/26/2019 (mm/dd/yyyy) Page 1 of 1 Personal Detail First Name: Last Name: KARYNA SHULIAK Addresses License Related Addresses Address of Record Warning: Confidential Address Warning: In order to protect your privacy and identity, address will not be displayed. 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