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General NPI Number Information
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NPI Number | 1649765629
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Entity Type | Individual
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Provider Name | NOSAKHARE IDEHEN DMD
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Gender | Male
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Dates
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Enumeration Date | 06/22/2018
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Last Update Date | 06/22/2018
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Provider Practice Location Address
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Address Line | 1809 TULANE DR
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City | LUFKIN
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State | TX
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Zip | 75901-5637
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Country | US
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Telephone | 936-628-4070
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Fax |
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Provider Business Mailing Address
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Address Line | 2210 OAK FOREST DR
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City | GARLAND
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State | TX
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Zip | 75042-3934
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Country | US
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Telephone | 214-382-7440
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 34279
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License Number State | TX
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