Healthcare Provider Details

I. General information

NPI: 1063561686
Provider Name (Legal Business Name): JOHNATHAN CALLIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 S CAPITAL OF TEXAS HWY SUITE A-2
AUSTIN TX
78746-8101
US

IV. Provider business mailing address

3701 KIRBY DR SUITE 550
HOUSTON TX
77098-3900
US

V. Phone/Fax

Practice location:
  • Phone: 512-328-4867
  • Fax:
Mailing address:
  • Phone: 512-328-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20343
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: