=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013571595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLAGOKE MASHA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2019
-----------------------------------------------------
Last Update Date | 09/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12609 S GESSNER RD STE F
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77071-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-978-2649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14414 MERGANSER DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77047-4633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-978-2649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 36148
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------