MEDICARE: DVA PLASTIC SURGERY, PLLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1356199145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA PLASTIC SURGERY, PLLC

Provider Business Mailing Address
First Line	:	1110 W GRAY ST STE 210
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77019-4157
Country	:	US
Telephone Number	:	713-581-1858
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 W GRAY ST STE 210
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77019-4157
Country	:	US
Telephone Number	:	713-581-1858
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DARE AJIBADE
Credential	:	MD
Telephone Number	:	352-620-5211

Provider Enumeration Date	:	05/08/2024
Last Update Date	:	05/09/2024

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