Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | D-4121-OR | ID |
NPI | 1053597245 |
---|---|
Provider Name | Dr. Loren E. Short |
First Address | Caldwell, ID 83607-5006 |
Second Address | Caldwell, ID 83607-5006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2008 |
Last Update Date | 17/01/2008 |