Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 25953 | TX |
NPI | 1245513209 |
---|---|
Provider Name | Mr. Kevin L Haywood SR. |
First Address | Fort Worth, TX 76108-7948 |
Second Address | Fort Worth, TX 76109-3700 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2011 |
Last Update Date | 26/09/2011 |