Provider Demographics
NPI:1215544564
Name:NTABANA, UMUHIRE
Entity type:Individual
Prefix:
First Name:UMUHIRE
Middle Name:
Last Name:NTABANA
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 1:20 MAVERICK SQ
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2335
Mailing Address - Country:US
Mailing Address - Phone:617-568-4872
Mailing Address - Fax:
Practice Address - Street 1:20 MAVERICK SQ
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2335
Practice Address - Country:US
Practice Address - Phone:617-568-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN100000121223D0001X
NC12115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Yes1223D0001XDental ProvidersDentistDental Public Health