Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | LD17 | ID |
NPI | 1770658767 |
---|---|
Provider Name | Terry L. Barnes |
First Address | Burley, ID 83318-1513 |
Second Address | Burley, ID 83318-1513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2006 |
Last Update Date | 09/07/2007 |