Provider Demographics
NPI:1215544564
Name:NTABANA, UMUHIRE
Entity Type:Individual
Prefix:
First Name:UMUHIRE
Middle Name:
Last Name:NTABANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 JAKE ALEXANDER BLVD W STE 103
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1385
Mailing Address - Country:US
Mailing Address - Phone:704-519-2366
Mailing Address - Fax:
Practice Address - Street 1:712 WOODRUFF PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-4552
Practice Address - Country:US
Practice Address - Phone:980-422-5919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC12115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program