Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DS-029503-L | PA |
NPI | 1043498306 |
---|---|
Provider Name | Dr. Pouya Hatam-Ebrahimi |
First Address | Blue Bell, PA 19422-1223 |
Second Address | Blue Bell, PA 19422-1223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2008 |
Last Update Date | 08/02/2008 |