Healthcare Provider Details

I. General information

NPI: 1144516329
Provider Name (Legal Business Name): CHINATU P EGO-OSUALA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 11/20/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 CARROLL AVE 480
TAKOMA PARK MD
20912-6384
US

IV. Provider business mailing address

7610 CARROLL AVE 480
TAKOMA PARK MD
20912-6384
US

V. Phone/Fax

Practice location:
  • Phone: 301-326-1302
  • Fax: 301-326-1092
Mailing address:
  • Phone: 301-326-1302
  • Fax: 301-326-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15803
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: