MEDICARE: DR. JUANITA OKEMWA B.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	51689	CA

General Provider Information

NPI Number	:	1760484463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUANITA OKEMWA B.D.S.

Provider Business Mailing Address
First Line	:	117 S LOS ROBLES AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-2417
Country	:	US
Telephone Number	:	626-585-9455
Fax Number	:	626-449-4932

Provider Business Practice Location Address
First Line	:	10842 WASHINGTON BLVD
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-3610
Country	:	US
Telephone Number	:	310-559-2935
Fax Number	:	310-559-0859

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	08/21/2007

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