Provider Demographics
NPI:1477886695
Name:DADA, BOLATITO GRACE (MD)
Entity Type:Individual
Prefix:MRS
First Name:BOLATITO
Middle Name:GRACE
Last Name:DADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:BOLATITO
Other - Middle Name:GRACE
Other - Last Name:FAMODIMU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15802 MISSION VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-2338
Mailing Address - Country:US
Mailing Address - Phone:281-323-8656
Mailing Address - Fax:800-896-0760
Practice Address - Street 1:15802 MISSION VILLAGE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-2338
Practice Address - Country:US
Practice Address - Phone:281-323-8656
Practice Address - Fax:800-896-0760
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA08186829374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide