Healthcare Provider Details

I. General information

NPI: 1477972073
Provider Name (Legal Business Name): CHIJIOKE ONYINYECHUKWU ESEONU DMD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ADMIRAL TROST RD STE B
COLUMBIA IL
62236-2163
US

IV. Provider business mailing address

609 SILENT CREEK CV
GEORGETOWN TX
78628-2970
US

V. Phone/Fax

Practice location:
  • Phone: 618-344-3456
  • Fax: 618-206-2631
Mailing address:
  • Phone: 804-920-4838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number36040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: