Individual
JIM J IM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
79TH DS, BLDG 1601, ANDREWS AFB, MD 20762
(240) 857-5029
Mailing address
9320 VAN GUARD CT, OWINGS MILLS, MD 21117-8291
(714) 833-0536
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
13490
MD
Other
Enumeration date
11/14/2005
Last updated
07/08/2007
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