Healthcare Provider Details

I. General information

NPI: 1417444332
Provider Name (Legal Business Name): EBOSETALE ODIAOGBE OKORUWA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6936 PINE ARBOR DR S STE 230
COTTAGE GROVE MN
55016-4645
US

IV. Provider business mailing address

2052 IRENE ST
ROSEVILLE MN
55113-6613
US

V. Phone/Fax

Practice location:
  • Phone: 651-204-5257
  • Fax:
Mailing address:
  • Phone: 712-309-6588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1002470
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14478
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: