Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000423 | WA |
NPI | 1417150038 |
---|---|
Provider Name | Christian Rene Iturriaga |
First Address | Federal Way, WA 98023-5056 |
Second Address | Prosser, WA 99350-1423 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2007 |
Last Update Date | 19/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5049226 | (05) | WA |