Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD23 | ID |
NPI | 1316125479 |
---|---|
Provider Name | Mr. Jeffrey Alan Kollmann |
First Address | Nampa, ID 83651 |
Second Address | Nampa, ID 83651 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2008 |
Last Update Date | 31/01/2008 |