Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000002 | WA |
NPI | 1265642854 |
---|---|
Provider Name | Jody Eric Hansen |
First Address | Bellingham, WA 98225-2411 |
Second Address | Bellingham, WA 98225-2411 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5020052 | (05) | WA |
DN00000002 | WA DENTURIST LICENSE # (01) | WA |