Individual
Inactive
Sole proprietor
Provider details
NPI number
Contact information
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DS0208106
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
112147
CONCORDIA
PA
Enumeration date
—
Last updated
—
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