Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | DS019246L | PA |
NPI | 1104956499 |
---|---|
Provider Name | Dr. John W Gruendel JR. |
First Address | Gibsonia, PA 15044-9200 |
Second Address | Gibsonia, PA 15044-9200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DL019246L | STATE LICENSE (01) | PA |