Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD-53 | ID |
NPI | 1013151083 |
---|---|
Provider Name | Glen M Castor |
First Address | Nampa, ID 83651-4246 |
Second Address | Nampa, ID 83651-4246 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2009 |
Last Update Date | 21/04/2009 |