Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD33 | ID |
NPI | 1205996915 |
---|---|
Provider Name | Mr. Aaron Kent Dickinson |
First Address | Lewiston, ID 83501 |
Second Address | Lewiston, ID 83501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2006 |
Last Update Date | 15/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002560200 | (05) | ID |