Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000126 | WA |
NPI | 1427275742 |
---|---|
Provider Name | Roger Mitchell |
First Address | Spokane Valley, WA 99212-0631 |
Second Address | Spokane Valley, WA 99212-0631 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5022520 | (05) | WA |