MEDICARE: ROLI GRACE OKOTIE-EBOH

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	37845	TX

General Provider Information

NPI Number	:	1427726280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROLI GRACE OKOTIE-EBOH

Provider Business Mailing Address
First Line	:	16520 STEINHAGEN RD
Second Line	:
City	:	CYPRESS
State	:	TX
Zip	:	77429-7173
Country	:	US
Telephone Number	:	281-650-7513
Fax Number	:

Provider Business Practice Location Address
First Line	:	1911 TAYLOR ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3990
Country	:	US
Telephone Number	:	713-868-4488
Fax Number	:

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

Provider Enumeration Date	:	09/05/2021
Last Update Date	:	09/05/2021

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