Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 018.002071 | NC |
NPI | 1033603030 |
---|---|
Provider Name | Dr. Marcus Ryan Gillon |
First Address | Houston, TX 77054-6010 |
Second Address | Houston, TX 77054 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2018 |
Last Update Date | 05/06/2019 |