Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-1008766 | OR |
NPI | 1598979429 |
---|---|
Provider Name | Mr. John Tatos |
First Address | Cottage Grove, OR 97424-9363 |
Second Address | Cottage Grove, OR 97424-9363 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2007 |
Last Update Date | 08/07/2007 |