Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD115 | ID |
NPI | 1538672837 |
---|---|
Provider Name | Angelo B Giovanini |
First Address | Nampa, ID 83686-6182 |
Second Address | Nampa, ID 83686-6182 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2017 |
Last Update Date | 08/11/2017 |