Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | D10744 | OR |
Y | 204E00000X | Oral & Maxillofacial Surgeon | PG199590 | OR |
NPI | 1164937769 |
---|---|
Provider Name | Dr. Michael Danger Whitcomb |
First Address | Portland, OR 97209-2693 |
Second Address | Portland, OR 97239-3011 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2017 |
Last Update Date | 21/07/2020 |