MEDICARE: JUSTIN NWOSU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	D15172	MN

General Provider Information

NPI Number	:	1104673227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN NWOSU

Provider Business Mailing Address
First Line	:	2000 PIN OAK PKWY
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-3098
Country	:	US
Telephone Number	:	301-653-5145
Fax Number	:

Provider Business Practice Location Address
First Line	:	7936 PORTLAND AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-1315
Country	:	US
Telephone Number	:	952-852-7776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2024
Last Update Date	:	07/17/2024

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Directions to “ JUSTIN NWOSU ” Practice Location

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