Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD 36 | ID |
NPI | 1558440313 |
---|---|
Provider Name | Mr. Jonathan Ragner Sander |
First Address | Buhl, ID 83316-1602 |
Second Address | Buhl, ID 83316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2006 |
Last Update Date | 08/07/2007 |