Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | DEN4410 | ME |
NPI | 1144741570 |
---|---|
Provider Name | Dr. Wyatt John Traina |
First Address | Portland, ME 04103-1523 |
Second Address | Portland, ME 04102-1988 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2017 |
Last Update Date | 06/07/2017 |