Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-10190663 | OR |
NPI | 1285213090 |
---|---|
Provider Name | Avery Ralston |
First Address | Eugene, OR 97401-3519 |
Second Address | Eugene, OR 97401-3519 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2021 |
Last Update Date | 07/04/2021 |