Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-433361 | OR |
NPI | 1801034335 |
---|---|
Provider Name | Dan Joseph Dettmann |
First Address | Junction City, OR 97448-1525 |
Second Address | Corvallis, OR 97333-2248 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/01/2009 |
Last Update Date | 21/01/2009 |