Healthcare Provider Details

I. General information

NPI: 1730619438
Provider Name (Legal Business Name): DELIS OGANDO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N JACKSON ST
JACKSON MI
49201-1266
US

IV. Provider business mailing address

374 WADSWORTH AVE APT 1A
NEW YORK NY
10040-3110
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax:
Mailing address:
  • Phone: 929-304-6521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License Number11111111
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: