MEDICARE: DR. ANITA OGHOGHO IMADOMWANYI D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	25180	TX

General Provider Information

NPI Number	:	1164740015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANITA OGHOGHO IMADOMWANYI D.D.S.

Provider Business Mailing Address
First Line	:	533 S ST ANDREWS PL
Second Line	:	APT #210
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-5300
Country	:	US
Telephone Number	:	214-476-2157
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 S BUCKNER BLVD
Second Line	:	STE #223
City	:	DALLAS
State	:	TX
Zip	:	75217-1760
Country	:	US
Telephone Number	:	214-391-6868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2010
Last Update Date	:	05/16/2010

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