Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN60142153 | WA |
NPI | 1871040378 |
---|---|
Provider Name | Ephraim Rollolazo JR. |
First Address | Everett, WA 98201 |
Second Address | Everett, WA 98201-4200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 01/09/2016 |