Healthcare Provider Details

I. General information

NPI: 1356875462
Provider Name (Legal Business Name): KENECHUKWU NWANKWO D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 PRESIDENT GEORGE BUSH HWY STE 140
ROWLETT TX
75089-3694
US

IV. Provider business mailing address

2817 GARDEN OAKS PL
GRAND PRAIRIE TX
75052-4402
US

V. Phone/Fax

Practice location:
  • Phone: 214-703-0703
  • Fax:
Mailing address:
  • Phone: 972-816-8861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33588
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number33588
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: