Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD18 | ID |
NPI | 1720124324 |
---|---|
Provider Name | Mrs. Bonnie Jean Devall |
First Address | Twin Falls, ID 83301 |
Second Address | Twin Falls, ID 83301 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001191300 | (05) | ID |