Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD-98 | ID |
NPI | 1205365632 |
---|---|
Provider Name | Geno Alan Giovanini |
First Address | Pocatello, ID 83201-4052 |
Second Address | Pocatello, ID 83201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2017 |
Last Update Date | 08/06/2017 |