=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093334971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWKPEZI ABIDE YAWA BAGNABANA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2020
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1509 CEDAR CLIFF DR
-----------------------------------------------------
City | CAMP HILL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17011-7720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-999-5655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1509 CEDAR CLIFF DR
-----------------------------------------------------
City | CAMP HILL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17011-7720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-999-5605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS043396
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------