=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427502921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILFRED OMOGHIBORA UKHUREBOR DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2016
-----------------------------------------------------
Last Update Date | 02/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 N CENTER ST STE 100
-----------------------------------------------------
City | BONHAM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75418-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-304-5810
-----------------------------------------------------
Fax | 903-304-5808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 NE 7TH AVE
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79107-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-761-6990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 32166
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 32166
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------