Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN 60208462 | WA |
NPI | 1881961779 |
---|---|
Provider Name | Travis Christoph Fagala |
First Address | Walla Walla, WA 99362-3002 |
Second Address | Walla Walla, WA 99362-3002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2011 |
Last Update Date | 21/11/2011 |