Healthcare Provider Details

I. General information

NPI: 1952840274
Provider Name (Legal Business Name): ONYINYECHI KELECHUKWU ESONU DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W NORTH AVE
MELROSE PARK IL
60160-1671
US

IV. Provider business mailing address

620 W NORTH AVE
MELROSE PARK IL
60160-1671
US

V. Phone/Fax

Practice location:
  • Phone: 708-316-2056
  • Fax:
Mailing address:
  • Phone: 708-316-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.034118
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDR60757258
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: