Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | UTSA 756X | TX |
NPI | 1043494420 |
---|---|
Provider Name | Jana-Marie Danielle Koylass |
First Address | San Antonio, TX 78240-3991 |
Second Address | San Antonio, TX 78229-3901 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2007 |
Last Update Date | 21/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
20142555 | UTSA 756X (01) |