Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 12013182A | IN |
NPI | 1003474040 |
---|---|
Provider Name | Noah Menaker |
First Address | Indianapolis, IN 46202-5109 |
Second Address | Indianapolis, IN 46202-5109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2019 |
Last Update Date | 04/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12013182A | DENTAL LICENSE NUMBER (01) | IN |