Basic Information
Provider Information
NPI: 1720606940
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OZUMBA
FirstName: BETHEL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10333 CLAY RD APT 2030
Address2:  
City: HOUSTON
State: TX
PostalCode: 770418766
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 7031 HIGHWAY 6 N
Address2:  
City: HOUSTON
State: TX
PostalCode: 770952505
CountryCode: US
TelephoneNumber: 2818591425
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/14/2020
LastUpdateDate: 07/14/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 07/14/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X36263TXY Dental ProvidersDentist 

No ID Information.


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