Healthcare Provider Details

I. General information

NPI: 1215427513
Provider Name (Legal Business Name): ADESUWA OKONEDO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADSUWA OKONEDO DDS

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 W PLEASANT RUN RD STE 190
LANCASTER TX
75146-1041
US

IV. Provider business mailing address

2611 ROSS AVE APT 5038
DALLAS TX
75201-2558
US

V. Phone/Fax

Practice location:
  • Phone: 469-765-8050
  • Fax:
Mailing address:
  • Phone: 202-468-8164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number34042
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: