Provider Demographics
NPI:1609531839
Name:OMO-OKHUASUYI, AIYEVBEKPEN
Entity Type:Individual
Prefix:
First Name:AIYEVBEKPEN
Middle Name:
Last Name:OMO-OKHUASUYI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9827 MARBACH CRST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-4476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:432 S BIBB AVE STE 300
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5390
Practice Address - Country:US
Practice Address - Phone:409-203-9562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX379891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice