Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000259 | WA |
NPI | 1629446364 |
---|---|
Provider Name | Jorge Abel Vizcarra |
First Address | Seattle, WA 98125-4490 |
Second Address | Seattle, WA 98125-4490 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2015 |
Last Update Date | 11/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DSHS 5057865 | DSHS PROVIDER (01) | WA |