Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000045 | WA |
NPI | 1194960161 |
---|---|
Provider Name | Mr. Larry Lee Pevny |
First Address | Marysville, WA 98270-4532 |
Second Address | Marysville, WA 98270-4532 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2008 |
Last Update Date | 04/12/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1336278910 | ORGANIZATIONAL NPI NUMBER (01) | WA |