MEDICARE: MISS EDMOND EBUBECHUKWU ONWUKWE

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	1223E0200X	Endodontics	30.027110	OH
2	390200000X	Student in an Organized Health Care Education/Training Program		CA
3	1223E0200X	Endodontics	10989	KY

General Provider Information

NPI Number	:	1699397984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS EDMOND EBUBECHUKWU ONWUKWE

Provider Business Mailing Address
First Line	:	1220 W 35TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-3444
Country	:	US
Telephone Number	:	301-768-9678
Fax Number	:

Provider Business Practice Location Address
First Line	:	11212 PROFESSIONAL PARK DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-4476
Country	:	US
Telephone Number	:	502-742-2168
Fax Number	:

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

Provider Enumeration Date	:	05/11/2020
Last Update Date	:	06/27/2023

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