Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DEN.00204746 | CO |
NPI | 1003486093 |
---|---|
Provider Name | Dr. Kai Pedersen |
First Address | Tacoma, WA 98431-0001 |
Second Address | Tacoma, WA 98431-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2021 |
Last Update Date | 30/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DEN.00204746 | STATE LICENSE (01) | CO |