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General NPI Number Information
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NPI Number | 1568838043
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Entity Type | Organization
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Legal Business Name | WOODLAWN DENTAL GALLERY
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Dates
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Enumeration Date | 08/19/2015
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Last Update Date | 08/19/2015
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Provider Practice Location Address
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Address Line | 1502 E 63RD ST
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City | CHICAGO
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State | IL
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Zip | 60637-2921
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Country | US
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Telephone | 773-496-5138
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Fax | 773-496-5142
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Provider Business Mailing Address
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Address Line | 8544 S STONY ISLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60617-2248
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Country | US
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Telephone | 773-221-0800
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Fax | 773-221-0868
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. OGBONNA BANKOLE BOWDEN
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Credential | DDS
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Telephone | 773-793-1220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019027749
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License Number State | IL
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