Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DE00009045 | WA |
NPI | 1033403001 |
---|---|
Provider Name | Derek Boyden |
First Address | Gig Harbor, WA 98335-1778 |
Second Address | Gig Harbor, WA 98335-1778 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2011 |
Last Update Date | 07/06/2011 |