Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | D4180 | OR |
NPI | 1013106681 |
---|---|
Provider Name | Stephen Gordon Woodyard |
First Address | Portland, OR 97225-5176 |
Second Address | Portland, OR 97225-5176 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2007 |
Last Update Date | 19/10/2007 |