Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-10189132 | OR |
N | 124Q00000X | Dental Hygienist | H5633 | OR |
NPI | 1407153612 |
---|---|
Provider Name | John Matthew Tripp |
First Address | Grants Pass, OR 97526-4114 |
Second Address | Grants Pass, OR 97526-1361 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2011 |
Last Update Date | 20/12/2019 |