Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD-111 | ID |
NPI | 1093165524 |
---|---|
Provider Name | Cody Waid |
First Address | Idaho Falls, ID 83401-3929 |
Second Address | Meridian, ID 83646-1921 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2016 |
Last Update Date | 15/06/2016 |