Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 30187 | TX |
Y | 1223X0400X | Orthodontists | 30187 | TX |
NPI | 1023407814 |
---|---|
Provider Name | Dr. Michael Ross |
First Address | Amarillo, TX 79119-1238 |
Second Address | Dallas, TX 75246-2013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2015 |
Last Update Date | 22/06/2021 |