Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 20343 | TX |
NPI | 1063561686 |
---|---|
Provider Name | Johnathan Callia |
First Address | Houston, TX 77098-3900 |
Second Address | Austin, TX 78746-8101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2007 |
Last Update Date | 08/07/2007 |