Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 60310 | CA |
N | 1223P0300X | Periodontist | 8188 | AZ |
NPI | 1073765053 |
---|---|
Provider Name | Ryan David Harbertson |
First Address | Escondido, CA 92025-3435 |
Second Address | Escondido, CA 92025-3435 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2008 |
Last Update Date | 29/05/2012 |