Provider Demographics
NPI:1225595416
Name:MBADU, MARCIA PHEMBA (DMD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:PHEMBA
Last Name:MBADU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 MILWAUKEE AVE APT 1701
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3707
Mailing Address - Country:US
Mailing Address - Phone:630-901-2819
Mailing Address - Fax:
Practice Address - Street 1:4415 66TH ST STE 112
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-4811
Practice Address - Country:US
Practice Address - Phone:903-758-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDRPM2049390200000X
TX387771223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program