Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTDO10126518 | OR |
NPI | 1023347945 |
---|---|
Provider Name | John Gordon Wilson |
First Address | Baker City, OR 97814-6183 |
Second Address | Baker City, OR 97814-6183 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/12/2009 |
Last Update Date | 02/02/2012 |