Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 27064 | TX |
NPI | 1003103326 |
---|---|
Provider Name | Mr. Mohammad Moridnia |
First Address | Brookshire, TX 77423 |
Second Address | Brookshire, TX 77423 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2011 |
Last Update Date | 08/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
27064 | (05) | TX |