Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN 60188130 | WA |
NPI | 1255678819 |
---|---|
Provider Name | Mr. Perry Balcom |
First Address | Issaquah, WA 98027-5389 |
Second Address | Issaquah, WA 98027-5389 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2013 |
Last Update Date | 15/01/2013 |