Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 1 | MT |
NPI | 1063540474 |
---|---|
Provider Name | Lee Wiser |
First Address | Bozeman, MT 59718-3100 |
Second Address | Bozeman, MT 59715-2500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000150042 | (05) | MT |