Healthcare Provider Details

I. General information

NPI: 1942552500
Provider Name (Legal Business Name): TABITHA IKPECHUKWU EFOBI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6570 SHALLOWFORD RD
LEWISVILLE NC
27023-8651
US

IV. Provider business mailing address

6570 SHALLOWFORD RD
LEWISVILLE NC
27023-8651
US

V. Phone/Fax

Practice location:
  • Phone: 757-831-6852
  • Fax:
Mailing address:
  • Phone: 757-831-6852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9408
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1942552500
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: