MEDICARE: DR. IFEANYI N. EZUNU DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	012240	GA

General Provider Information

NPI Number	:	1588603971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IFEANYI N. EZUNU DDS

Provider Business Mailing Address
First Line	:	6460 SPALDING DR
Second Line	:	SUITE C
City	:	NORCROSS
State	:	GA
Zip	:	30092-1805
Country	:	US
Telephone Number	:	770-263-8408
Fax Number	:	770-263-8954

Provider Business Practice Location Address
First Line	:	6460 SPALDING DR
Second Line	:	SUITE C
City	:	NORCROSS
State	:	GA
Zip	:	30092-1805
Country	:	US
Telephone Number	:	770-263-8408
Fax Number	:	770-263-8954

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	07/08/2007

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