Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122400000X | Denturist | ||
N | 122400000X | Denturist | 118 | ID |
Y | 122400000X | Denturist | LD-118 | ID |
NPI | 1063064053 |
---|---|
Provider Name | Miss Kyrsten M Wooldridge |
First Address | Twin Falls, ID 83301-3056 |
Second Address | Twin Falls, ID 83301-3056 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2019 |
Last Update Date | 10/07/2019 |