Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 11582 | TX |
NPI | 1003929506 |
---|---|
Provider Name | Douglas Jay Conquest |
First Address | Round Rock, TX 78681-4943 |
Second Address | Round Rock, TX 78681-4943 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2006 |
Last Update Date | 04/12/2008 |