Provider Demographics
NPI:1760864797
Name:MBA, CHI
Entity Type:Individual
Prefix:DR
First Name:CHI
Middle Name:
Last Name:MBA
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 1:610 PINE VLY
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5138
Mailing Address - Country:US
Mailing Address - Phone:713-213-2658
Mailing Address - Fax:
Practice Address - Street 1:8620 SKILLMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-8216
Practice Address - Country:US
Practice Address - Phone:214-341-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30951122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist