Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 35413 | TX |
NPI | 1487215018 |
---|---|
Provider Name | Keyvan Namazi Matteo |
First Address | Waco, TX 76708-7501 |
Second Address | Bellmead, TX 76705-2868 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2019 |
Last Update Date | 25/06/2019 |