Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD44 | ID |
NPI | 1629115761 |
---|---|
Provider Name | Mr. Gennady S Babichenko |
First Address | Boise, ID 83704-5477 |
Second Address | Boise, ID 83704-5477 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 08/07/2007 |