Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000046 | WA |
NPI | 1538625561 |
---|---|
Provider Name | Mr. Clinton Jerrod Olson |
First Address | Clarkston, WA 99403 |
Second Address | Clarkston, WA 99403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2019 |
Last Update Date | 14/02/2019 |