Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-1003340 | OR |
NPI | 1740413012 |
---|---|
Provider Name | Mr. Anthony Ray Belisle JR. |
First Address | Coos Bay, OR 97420-0418 |
Second Address | Coos Bay, OR 97420-1401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2009 |
Last Update Date | 02/09/2009 |