Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 101 | ID |
NPI | 1366800583 |
---|---|
Provider Name | Nicholas Sander |
First Address | Buhl, ID 83316-1602 |
Second Address | Buhl, ID 83316-1602 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2016 |
Last Update Date | 02/02/2016 |