Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 13345 | MD |
NPI | 1003897927 |
---|---|
Provider Name | Mr. Brian Toms Wycall |
First Address | Baltimore, MD 21224-4810 |
Second Address | Baltimore, MD 21224-4208 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2005 |
Last Update Date | 08/07/2007 |