Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-854277 | OR |
NPI | 1649381062 |
---|---|
Provider Name | Mr. Kevin M Tatlock |
First Address | Ontario, OR 97914-3201 |
Second Address | Ontario, OR 97914-3201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
125851 | (05) | OR |