Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTDO355212 | OR |
NPI | 1235570961 |
---|---|
Provider Name | Randall Scott Clasen |
First Address | Roseburg, OR 97470-3260 |
Second Address | Roseburg, OR 97470-3260 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2013 |
Last Update Date | 30/07/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
86-114979 | TAX ID (01) | OR |