Healthcare Provider Details

I. General information

NPI: 1477122539
Provider Name (Legal Business Name): OKEYSOLOM KENNETH ORADIEGWU JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KESO KENNETH ORADIEGWU JR. DDS

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 S RANGE LINE RD STE D
JOPLIN MO
64804-3277
US

IV. Provider business mailing address

112 SE H ST APT 201
BENTONVILLE AR
72712-2712
US

V. Phone/Fax

Practice location:
  • Phone: 417-572-0002
  • Fax:
Mailing address:
  • Phone: 281-745-4691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37266
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2026033944
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: