Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000366 | WA |
NPI | 1255549747 |
---|---|
Provider Name | Renato G. Antonio |
First Address | Bremerton, WA 98310-3440 |
Second Address | Bremerton, WA 98310-3440 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2007 |
Last Update Date | 22/05/2013 |