Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT DO 981893 | OR |
NPI | 1487851614 |
---|---|
Provider Name | Ms. Susan Mary Stovall |
First Address | Clackamas, OR 97015-9587 |
Second Address | Clackamas, OR 97014 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2007 |
Last Update Date | 08/07/2007 |