Healthcare Provider Details

I. General information

NPI: 1013441831
Provider Name (Legal Business Name): KAYCEE OBI-GWACHAM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 WALTERS DIVISION RD
MONROE NC
28110
US

IV. Provider business mailing address

19810 W CATAWBA AVE # A1
CORNELIUS NC
28031-4056
US

V. Phone/Fax

Practice location:
  • Phone: 704-289-1105
  • Fax:
Mailing address:
  • Phone: 910-644-2884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11139
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: