Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 16254 | MA |
NPI | 1083620819 |
---|---|
Provider Name | Dr. Lawrence L. Phan |
First Address | Brookline, MA 02446-3282 |
Second Address | Brookline, MA 02446-3282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 08/07/2007 |