Provider Demographics
NPI:1063561686
Name:CALLIA, JOHNATHAN
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:CALLIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 KIRBY DR
Mailing Address - Street 2:SUITE 550
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-3900
Mailing Address - Country:US
Mailing Address - Phone:512-328-4867
Mailing Address - Fax:
Practice Address - Street 1:2901 S CAPITAL OF TEXAS HWY
Practice Address - Street 2:SUITE A-2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-8101
Practice Address - Country:US
Practice Address - Phone:512-328-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics