Healthcare Provider Details

I. General information

NPI: 1922187517
Provider Name (Legal Business Name): OKUMU DENTAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 OLIVE ST
COATESVILLE PA
19320-3518
US

IV. Provider business mailing address

1131 OLIVE ST
COATESVILLE PA
19320-3518
US

V. Phone/Fax

Practice location:
  • Phone: 610-466-9545
  • Fax: 610-466-9545
Mailing address:
  • Phone: 610-466-9545
  • Fax: 610-466-9545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS036492
License Number StatePA

VIII. Authorized Official

Name: DR. WALTER OKUMU NGAJI-OKUMU
Title or Position: OWNER
Credential: DDS
Phone: 610-466-9545