Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D7468 | OR |
NPI | 1003015496 |
---|---|
Provider Name | Dr. Kenneth Byron Wiltbank |
First Address | Lake Oswego, OR 97034 |
Second Address | Lake Oswego, OR 97034-3056 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2007 |
Last Update Date | 16/07/2007 |