Provider Demographics
NPI:1417262684
Name:ODHIAMBO, ANGELINA (DDS)
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:ODHIAMBO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3520
Mailing Address - Country:US
Mailing Address - Phone:903-984-1108
Mailing Address - Fax:
Practice Address - Street 1:1806 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3520
Practice Address - Country:US
Practice Address - Phone:903-984-1108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX276171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice