Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 25896 | TX |
Y | 1223P0300X | Periodontist | 25896 | TX |
NPI | 1154631133 |
---|---|
Provider Name | Dr. Joseph Fernando Capetillo |
First Address | Apo, AP 96205 |
Second Address | Fort Hood, TX 76544 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/10/2010 |
Last Update Date | 06/08/2018 |