=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326704693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ITAGEGNEHOU GEDAMU DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2021
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20991 ARSENAL STREET RD
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-4552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-785-9620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70887
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44190-0887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ITAGEGNEHOU GEDAMU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-785-9620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------