Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-D-0501891 | OR |
NPI | 1083958011 |
---|---|
Provider Name | Mr. John W Cooper |
First Address | Klamath Falls, OR 97603 |
Second Address | Klamath Falls, OR 97603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2012 |
Last Update Date | 15/11/2012 |