Provider Demographics
NPI:1093880288
Name:EBO, IKECHUKWU P (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:IKECHUKWU
Middle Name:P
Last Name:EBO
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 GWINNETT DR.
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045
Mailing Address - Country:US
Mailing Address - Phone:770-963-5999
Mailing Address - Fax:770-963-6603
Practice Address - Street 1:650 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7439
Practice Address - Country:US
Practice Address - Phone:770-963-5999
Practice Address - Fax:770-963-6603
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013673122300000X
NC74271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902F3Medicaid
NC5901375Medicaid