Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 8726 | TX |
NPI | 1053439422 |
---|---|
Provider Name | Dr. Carl Braxton Stewart |
First Address | Richardson, TX 75080-1342 |
Second Address | Richardson, TX 75080-1342 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2007 |
Last Update Date | 08/07/2007 |