Provider Demographics
NPI:1992897870
Name:ATANG, AZIEBONG M (DDS)
Entity type:Individual
Prefix:MRS
First Name:AZIEBONG
Middle Name:M
Last Name:ATANG
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 1:2019 S SHAVER ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77502
Mailing Address - Country:US
Mailing Address - Phone:713-477-2900
Mailing Address - Fax:713-477-2995
Practice Address - Street 1:2019 S SHAVER ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502
Practice Address - Country:US
Practice Address - Phone:713-477-2900
Practice Address - Fax:713-477-2995
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143989503Medicaid