Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-671615 | OR |
NPI | 1699933424 |
---|---|
Provider Name | Timothy Alan Smith |
First Address | Sandy, OR 97055-0744 |
Second Address | Sandy, OR 97055-0744 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2008 |
Last Update Date | 29/05/2008 |