Provider Demographics
NPI:1639787617
Name:IYAMAH, SERRATU OMOSOMI
Entity Type:Individual
Prefix:
First Name:SERRATU
Middle Name:OMOSOMI
Last Name:IYAMAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 VILLAGE GREEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7042
Mailing Address - Country:US
Mailing Address - Phone:682-433-1116
Mailing Address - Fax:
Practice Address - Street 1:1758 NW 82ND ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-2356
Practice Address - Country:US
Practice Address - Phone:580-354-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist