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General NPI Number Information
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NPI Number | 1790130789
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Entity Type | Organization
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Legal Business Name | GULF COAST PEDIATRIC DENTAL SPECIALISTS PLLC
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 6318 FM 1488 RD STE 120
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City | MAGNOLIA
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State | TX
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Zip | 77354-2519
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Country | US
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Telephone | 281-985-9075
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Fax | 936-448-9862
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Provider Business Mailing Address
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Address Line | 3121 BUFFALO SPEEDWAY APT 5307
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City | HOUSTON
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State | TX
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Zip | 77098-1852
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Country | US
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Telephone | 352-333-0909
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | OLAMIDE OSUNDOLU ATANDA
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Credential | DMD
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Telephone | 352-333-0909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 30734
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License Number State | TX
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