Provider Demographics
NPI:1083283865
Name:OKONOBOH, SYDNEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SYDNEY
Middle Name:
Last Name:OKONOBOH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 CUMMING HWY STE 110
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8009
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:2030 CUMMING HWY STE 110
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8009
Practice Address - Country:US
Practice Address - Phone:678-818-8480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002585122300000X
GADN1225411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist