Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 19812 | TX |
NPI | 1194816520 |
---|---|
Provider Name | Marc Ryan Smith |
First Address | Pflugerville, TX 78660-2041 |
Second Address | Pflugerville, TX 78660-2041 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 08/07/2007 |