Provider Demographics
NPI:1164740015
Name:IMADOMWANYI, ANITA OGHOGHO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:OGHOGHO
Last Name:IMADOMWANYI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:
Other - Last Name:IMADOMWANYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:533 S ST ANDREWS PL
Mailing Address - Street 2:APT #210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-5300
Mailing Address - Country:US
Mailing Address - Phone:214-476-2157
Mailing Address - Fax:
Practice Address - Street 1:1515 S BUCKNER BLVD
Practice Address - Street 2:STE #223
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-1760
Practice Address - Country:US
Practice Address - Phone:214-391-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-16
Last Update Date:2010-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice