Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO 557317 | OR |
NPI | 1083825962 |
---|---|
Provider Name | Mr. Tad Wylie Burzynski |
First Address | Bend, OR 97701 |
Second Address | Bend, OR 97701-4709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2007 |
Last Update Date | 08/07/2007 |