Healthcare Provider Details

I. General information

NPI: 1235366261
Provider Name (Legal Business Name): ESEOGHENE ERHUVWUYOMA OKUGBAYE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N CUMMINGS DR
ALVARADO TX
76009-3258
US

IV. Provider business mailing address

905 N CUMMINGS DR
ALVARADO TX
76009-3258
US

V. Phone/Fax

Practice location:
  • Phone: 678-698-1440
  • Fax:
Mailing address:
  • Phone: 678-698-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1855156
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number26223
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number26223
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: