Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT DO773331 | OR |
NPI | 1750598751 |
---|---|
Provider Name | Samie C. Simon |
First Address | North Bend, OR 97459-1121 |
Second Address | North Bend, OR 97459-1121 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |