Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD-46 | ID |
NPI | 1659760684 |
---|---|
Provider Name | Charles Rollin Westerberg |
First Address | Boise, ID 83709 |
Second Address | Boise, ID 83709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2015 |
Last Update Date | 14/01/2015 |