Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 28582 | TX |
NPI | 1053657494 |
---|---|
Provider Name | Vani Pavan |
First Address | Grapevine, TX 76051-1210 |
Second Address | Marlin, TX 76661-2809 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2012 |
Last Update Date | 17/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1205490257 | (05) | TX |