Healthcare Provider Details

I. General information

NPI: 1427726280
Provider Name (Legal Business Name): ROLI GRACE OKOTIE-EBOH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 09/05/2021
Certification Date: 09/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 TAYLOR ST
HOUSTON TX
77007-3990
US

IV. Provider business mailing address

16520 STEINHAGEN RD
CYPRESS TX
77429-7173
US

V. Phone/Fax

Practice location:
  • Phone: 713-868-4488
  • Fax:
Mailing address:
  • Phone: 281-650-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37845
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: