Provider Demographics
NPI:1073740478
Name:ODHIAMBO, ANTONY OKINYI (DDS)
Entity Type:Individual
Prefix:
First Name:ANTONY
Middle Name:OKINYI
Last Name:ODHIAMBO
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 1:1499 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6814
Mailing Address - Country:US
Mailing Address - Phone:903-242-9777
Mailing Address - Fax:903-212-4210
Practice Address - Street 1:5605 OLD BULLARD RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4306
Practice Address - Country:US
Practice Address - Phone:903-747-3919
Practice Address - Fax:903-747-3923
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice