Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 62296 | CA |
NPI | 1003251323 |
---|---|
Provider Name | Dr. Ryan Walsh Mccomb |
First Address | Venice, CA 90291-5758 |
Second Address | Venice, CA 90291-5758 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/04/2013 |
Last Update Date | 30/04/2013 |