Healthcare Provider Details

I. General information

NPI: 1457153967
Provider Name (Legal Business Name): CHISOM ENI-KALU DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ
BROOKLYN NY
11212-3139
US

IV. Provider business mailing address

1818 N 53RD ST APT 113
PHILADELPHIA PA
19131-3250
US

V. Phone/Fax

Practice location:
  • Phone: 412-499-1693
  • Fax:
Mailing address:
  • Phone: 412-499-1693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18924
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: