Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019017049 | IL |
Y | 1223P0106X | Oral and Maxillofacial Pathology | 00033301 | WA |
NPI | 1982726105 |
---|---|
Provider Name | Gary Solberg |
First Address | Oak Harbor, WA 98277-2622 |
Second Address | Oak Harbor, WA 98277-2622 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2007 |
Last Update Date | 13/08/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D28413 | (02) | WA |