Provider Demographics
NPI:1003121500
Name:OMOIRAWUA, OSAGIEMWANGBON NICOSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:OSAGIEMWANGBON
Middle Name:NICOSON
Last Name:OMOIRAWUA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15035 WESTPARK DR
Mailing Address - Street 2:APT 203
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-3950
Mailing Address - Country:US
Mailing Address - Phone:713-366-9249
Mailing Address - Fax:
Practice Address - Street 1:15035 WESTPARK DR
Practice Address - Street 2:APT 203
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-3950
Practice Address - Country:US
Practice Address - Phone:713-366-9249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice