Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 0516028598 | OR |
NPI | 1902813348 |
---|---|
Provider Name | Mr. Vernon Arthur Martin |
First Address | Fairview, OR 97024-9737 |
Second Address | Portland, OR 97220-4456 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0516028598 | LICENSED DENTURIST (01) | OR |