Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | C274780 | CA |
NPI | 1760568901 |
---|---|
Provider Name | Walter D Dishell |
First Address | Encino, CA 91436-4314 |
Second Address | Encino, CA 91436-4314 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A33379 | (02) |