Healthcare Provider Details

I. General information

NPI: 1730013822
Provider Name (Legal Business Name): CHIDOZIE ASIEGBUNAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W 2ND ST
ROCK FALLS IL
61071-1005
US

IV. Provider business mailing address

4809 GATESMILLS AVE
CHARLOTTE NC
28213-4416
US

V. Phone/Fax

Practice location:
  • Phone: 704-430-0662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: