Provider Demographics
NPI:1447638283
Name:ORISAFUNMI, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ORISAFUNMI
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 1:6410 FANNIN ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3000
Mailing Address - Country:US
Mailing Address - Phone:713-500-5888
Mailing Address - Fax:713-500-0728
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:713-500-5888
Practice Address - Fax:713-500-0728
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice