Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 4375 | AL |
NPI | 1467567792 |
---|---|
Provider Name | Michael Terry Gardner |
First Address | San Antonio, TX 78236-5638 |
Second Address | San Antonio, TX 78236-5638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 08/03/2021 |