Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTDO10126042 | OR |
NPI | 1407100233 |
---|---|
Provider Name | Mr. Cody Merril Bywaters |
First Address | Lake Oswego, OR 97035-3446 |
Second Address | Lake Oswego, OR 97035-3446 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2012 |
Last Update Date | 31/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DTDO 10126042 | DENTURIST HEALTH LICENSE STATE OF OREGON (01) | OR |