Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | A30373 | OR |
N | 126800000X | Dental Assistant | D1 60053125 | WA |
NPI | 1205101201 |
---|---|
Provider Name | Mr. Patrick Stevens Edwards |
First Address | Portland, OR 97203-3426 |
Second Address | Portland, OR 97203-3426 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2012 |
Last Update Date | 09/03/2012 |