Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-10131106 | OR |
NPI | 1053697201 |
---|---|
Provider Name | Mrs. Kismet Mayo |
First Address | Brookings, OR 97415-0279 |
Second Address | Brookings, OR 97415-7153 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2011 |
Last Update Date | 01/11/2011 |