Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTO10154441 | OR |
NPI | 1154721850 |
---|---|
Provider Name | Mikhail Govshievich |
First Address | Lake Oswego, OR 97035-4472 |
Second Address | Portland, OR 97219 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2014 |
Last Update Date | 19/09/2014 |