Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTDO629849 | OR |
NPI | 1467571612 |
---|---|
Provider Name | Mr. Randy L Townsend |
First Address | Sweet Home, OR 97386-1608 |
Second Address | Sweet Home, OR 97386-1608 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DT.DO-629849 | DENTURIST ID. NUMBER (01) | OR |