Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 19478 | MA |
NPI | 1063567410 |
---|---|
Provider Name | Gijsbertus Brandse |
First Address | Cambridge, MA 02138-2317 |
Second Address | Cambridge, MA 02138-2317 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2007 |
Last Update Date | 08/07/2007 |