Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | DS022706L | PA |
NPI | 1396762308 |
---|---|
Provider Name | Dr. Joseph A Ilacqua |
First Address | Norristown, PA 19401 |
Second Address | Norristown, PA 19401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2006 |
Last Update Date | 01/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T71912 | (02) |