Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 025108DN00000270 | WA |
NPI | 1477548766 |
---|---|
Provider Name | Mr. Derek T Pawlak |
First Address | Lynden, WA 98264-9404 |
Second Address | Lynden, WA 98264-9404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
025108DN00000270 | DEPT OF HEALTH (01) | WA |
5036017 | (05) | WA |