Healthcare Provider Details

I. General information

NPI: 1144777939
Provider Name (Legal Business Name): EVARISTUS O OKOGIE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N MAIN ST
JONESBORO GA
30236-3226
US

IV. Provider business mailing address

3970 CRESTWATER LN
SNELLVILLE GA
30039-6838
US

V. Phone/Fax

Practice location:
  • Phone: 770-477-6868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015240
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: