Healthcare Provider Details

I. General information

NPI: 1790061745
Provider Name (Legal Business Name): OBIANUJU RITA MBAMALU DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11185 IHILANI WAY
BOYNTON BEACH FL
33437-7181
US

IV. Provider business mailing address

11185 IHILANI WAY
BOYNTON BEACH FL
33437-7181
US

V. Phone/Fax

Practice location:
  • Phone: 737-585-7659
  • Fax:
Mailing address:
  • Phone: 973-758-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22DI02434400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0556931
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN25776
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: