Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000325 | WA |
NPI | 1386839736 |
---|---|
Provider Name | Larisa Reznik |
First Address | Anderson Island, WA 98303 |
Second Address | Anderson Island, WA 98303 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2007 |
Last Update Date | 10/09/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5040068 | (05) | WA |