Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT DO 706283 | OR |
NPI | 1699198663 |
---|---|
Provider Name | Lillian Petersen |
First Address | Florence, OR 97439-0004 |
Second Address | Florence, OR 97439-0004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2014 |
Last Update Date | 23/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
122400000X | DENTURIST (01) | OR |