Provider Demographics
NPI:1720359383
Name:GRIFFITH, IFETAYO A (DMD)
Entity Type:Individual
Prefix:DR
First Name:IFETAYO
Middle Name:A
Last Name:GRIFFITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3000
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-8001
Mailing Address - Country:US
Mailing Address - Phone:713-523-1666
Mailing Address - Fax:713-523-8940
Practice Address - Street 1:8313 SOUTHWEST FWY STE 177
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1612
Practice Address - Country:US
Practice Address - Phone:713-523-1666
Practice Address - Fax:713-523-8940
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211561223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice