Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN00000290 | WA |
NPI | 1841605235 |
---|---|
Provider Name | Ronald Johnson |
First Address | Vancouver, WA 98683-7653 |
Second Address | Vancouver, WA 98662-6478 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2014 |
Last Update Date | 25/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1659484244 | (05) | WA |