Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 4 | MT |
NPI | 1134333719 |
---|---|
Provider Name | Frank Brisendine |
First Address | Lakeside, MT 59922-0728 |
Second Address | Lakeside, MT 59922-0728 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0150144 | (05) | MT |