Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000371 | WA |
NPI | 1518134006 |
---|---|
Provider Name | Robin Richard Wiederrich |
First Address | Bremerton, WA 98312-9730 |
Second Address | Bremerton, WA 98312-9730 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2008 |
Last Update Date | 13/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5046198 | (05) | WA |