Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0300X | Periodontist | 18105 | NJ |
Y | 1223P0300X | Periodontist | DS027843L | PA |
NPI | 1124139647 |
---|---|
Provider Name | Dr. Milita Ghassemzadeh Borguet |
First Address | Narberth, PA 19072-2206 |
Second Address | Narberth, PA 19072-2206 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 14/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
776058 | BLUE CROSS BLUE SHEILD (01) | PA |