=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720359383
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IFETAYO A GRIFFITH DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2012
-----------------------------------------------------
Last Update Date | 08/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8313 SOUTHWEST FWY STE 177
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77074-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-523-1666
-----------------------------------------------------
Fax | 713-523-8940
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3000
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-8001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-523-1666
-----------------------------------------------------
Fax | 713-523-8940
-----------------------------------------------------
=====================================================
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 | 21156
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 21156
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------