Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 28900 | CA |
NPI | 1043301609 |
---|---|
Provider Name | Dr. John Benjamin Avera |
First Address | Aptos, CA 95003-4076 |
Second Address | Aptos, CA 95003-4076 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2006 |
Last Update Date | 08/07/2007 |