Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-461580 | OR |
NPI | 1033462155 |
---|---|
Provider Name | Albert Anselmo Caccivio JR. |
First Address | Eugene, OR 97404-3228 |
Second Address | Eugene, OR 97404-3228 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2012 |
Last Update Date | 26/10/2012 |