Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTDO709602 | OR |
NPI | 1356791677 |
---|---|
Provider Name | Jeffrey Jacky |
First Address | Hills Boro, OR 97124 |
Second Address | Hillsboro, OR 97123-8575 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2016 |
Last Update Date | 29/09/2017 |