Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 416 | WA |
NPI | 1679782973 |
---|---|
Provider Name | Richard C Johnson |
First Address | Tacoma, WA 98406-4938 |
Second Address | Tacoma, WA 98406-4938 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5042817 | (05) | WA |