Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | DE7966 | WA |
NPI | 1063531051 |
---|---|
Provider Name | Dr. Derek Richard Damon |
First Address | Bellingham, WA 98225-1933 |
Second Address | Bellingham, WA 98225-1933 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2007 |
Last Update Date | 26/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0278932 | LABOR AND INDUSTRIES (01) | WA |