Doctor Name: | CARL RAY DETTWILER |
NPI Number: | 1285623819 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | M5110 |
Business Practice Address: | 2517 17th Sreet Suite B Lewiston, ID - 835010001 |
Business Phone Number: | 2087434373 |
Business Fax Number: | 2087433369 |
Mailing Address: | 2517 17th St, Suite B LEWISTON |
State: | ID |
Postal Code: | 835016311 |
Phone Number: | 2087434373 |
Fax Number: | 2087433369 |
NPI Enumeration Date: | 10/17/2005 |
NPI Last Update Date: | 02/13/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 174400000X |
License Number: | M5110 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Other Service Providers |
Taxonomy Classification: | Specialist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |