Healthcare Provider Details

I. General information

NPI: 1083283865
Provider Name (Legal Business Name): SYDNEY OKONOBOH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 CUMMING HWY STE 110
CANTON GA
30115-8009
US

IV. Provider business mailing address

2030 CUMMING HWY STE 110
CANTON GA
30115-8009
US

V. Phone/Fax

Practice location:
  • Phone: 678-818-8480
  • Fax:
Mailing address:
  • Phone: 315-454-6000
  • Fax: 866-803-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1002585
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122541
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: