=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285919902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KINGSLEY OISE MOMODU D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2011
-----------------------------------------------------
Last Update Date | 04/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 BREEZEWOOD AVE STE 1011
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-6040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-762-1987
-----------------------------------------------------
Fax | 910-779-1099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 BREEZEWOOD AVE STE 1011
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-6040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-762-1987
-----------------------------------------------------
Fax | 910-779-1099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9234
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------