Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD9 | ID |
NPI | 1609045681 |
---|---|
Provider Name | Ms. Carla Roxann Wolfrum |
First Address | Sandpoint, ID 83864-1275 |
Second Address | Sandpoint, ID 83864-1275 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/02/2008 |
Last Update Date | 25/02/2008 |