Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 260 | WA |
NPI | 1366560302 |
---|---|
Provider Name | Mr. John Anderson |
First Address | Lacey, WA 98503-1119 |
Second Address | Lacey, WA 98503-1119 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2007 |
Last Update Date | 08/07/2007 |