Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-TMP-10190928 | OR |
NPI | 1730679168 |
---|---|
Provider Name | Travis C. Briseno |
First Address | Hillsboro, OR 97124-5611 |
Second Address | Medford, OR 97504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2018 |
Last Update Date | 15/05/2018 |