Healthcare Provider Details

I. General information

NPI: 1164641940
Provider Name (Legal Business Name): UNONMOSEN ENIOLA OGUFERE D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6695 GRAND AVE SUITE E
GURNEE IL
60031-5268
US

IV. Provider business mailing address

6695 GRAND AVE SUITE E
GURNEE IL
60031-5268
US

V. Phone/Fax

Practice location:
  • Phone: 847-855-1445
  • Fax:
Mailing address:
  • Phone: 847-855-1445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19026580
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: