Healthcare Provider Details

I. General information

NPI: 1003710823
Provider Name (Legal Business Name): OMOYEMWEN RITA IGIEBOR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 ROOSEVELT BLVD FL 2
PHILADELPHIA PA
19149-2943
US

IV. Provider business mailing address

6404 ROOSEVELT BLVD FL 2
PHILADELPHIA PA
19149-2943
US

V. Phone/Fax

Practice location:
  • Phone: 215-288-6404
  • Fax:
Mailing address:
  • Phone: 215-288-6404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS046105
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: