Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0106X | Oral and Maxillofacial Pathology | 16961 | TX |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 16961 | TX |
NPI | 1750506598 |
---|---|
Provider Name | Dr. R. Theodore Fields JR. |
First Address | Dallas, TX 75225-5943 |
Second Address | Dallas, TX 75225-5930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2007 |
Last Update Date | 04/01/2021 |