Healthcare Provider Details

I. General information

NPI: 1669056446
Provider Name (Legal Business Name): AKUDO AMANDA OGUBUNKA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2021
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 YORK RD STE 105
COCKEYSVILLE MD
21030-2396
US

IV. Provider business mailing address

826 RYAN ST
BALTIMORE MD
21230-2122
US

V. Phone/Fax

Practice location:
  • Phone: 410-803-5587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17579
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: