Provider Demographics
NPI:1225690308
Name:IBETO, PAMELA OLUCHI (DDS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:OLUCHI
Last Name:IBETO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:OLUCHI
Other - Last Name:IBETO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8132 KIRBY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-1706
Mailing Address - Country:US
Mailing Address - Phone:713-797-9041
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 310
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3004
Practice Address - Country:US
Practice Address - Phone:704-906-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX361391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX238638782Medicaid