Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-188851 | OR |
NPI | 1730226333 |
---|---|
Provider Name | Michael Moga |
First Address | Beaverton, OR 97005-4714 |
Second Address | Beaverton, OR 97005-4714 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2007 |
Last Update Date | 08/07/2007 |