Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-916801 | OR |
NPI | 1952551848 |
---|---|
Provider Name | Mr. Edward Jerrold Cooper SR. |
First Address | Portland, OR 97266 |
Second Address | Portland, OR 97266 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2008 |
Last Update Date | 26/09/2008 |