Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO 0126668 | OR |
NPI | 1083946347 |
---|---|
Provider Name | Troy Stewart |
First Address | Baker City, OR 97814-3420 |
Second Address | Baker City, OR 97814-3420 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/02/2010 |
Last Update Date | 10/02/2010 |