Provider Demographics
NPI:1215446547
Name:IGHODARO, AMENZE (DDS)
Entity type:Individual
Prefix:DR
First Name:AMENZE
Middle Name:
Last Name:IGHODARO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NIMITZ WAY
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-4413
Mailing Address - Country:US
Mailing Address - Phone:214-469-7496
Mailing Address - Fax:
Practice Address - Street 1:2400 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2466
Practice Address - Country:US
Practice Address - Phone:870-330-4604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX335421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice