Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-609564 | OR |
NPI | 1932259397 |
---|---|
Provider Name | Jack R Elvin |
First Address | Albany, OR 97322-4872 |
Second Address | Albany, OR 97322-3295 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
071696 | (05) | OR |