Basic Information
| Provider Information | |||||||||
| NPI: | 1164740015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMADOMWANYI | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | OGHOGHO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IMADOMWANYI | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 533 S ST ANDREWS PL | ||||||||
| Address2: | APT #210 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900205300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144762157 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1515 S BUCKNER BLVD | ||||||||
| Address2: | STE #223 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752171760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143916868 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2010 | ||||||||
| LastUpdateDate: | 05/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 25180 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.