Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-10171882 | OR |
NPI | 1407364177 |
---|---|
Provider Name | Mr. Joseph Rider |
First Address | Redmond, OR 97756-1340 |
Second Address | Redmond, OR 97756-1340 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2018 |
Last Update Date | 16/01/2018 |