Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DS025205L | PA |
NPI | 1104810530 |
---|---|
Provider Name | Michael Rosenbaum |
First Address | Philadelphia, PA 19149-2943 |
Second Address | Philadelphia, PA 19149-2943 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2005 |
Last Update Date | 02/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001148784 | (05) | PA |