Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-10131109 | OR |
NPI | 1477993434 |
---|---|
Provider Name | Tatyana Nikolaevna Poleon |
First Address | Portland, OR 97213-6755 |
Second Address | Portland, OR 97213-6755 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2013 |
Last Update Date | 04/07/2013 |