Provider Demographics
NPI:1194018374
Name:NWOKOCHA, BONAVENTURE CHISOM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BONAVENTURE
Middle Name:CHISOM
Last Name:NWOKOCHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16420 57TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3728
Mailing Address - Country:US
Mailing Address - Phone:618-593-2130
Mailing Address - Fax:
Practice Address - Street 1:7960 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2722
Practice Address - Country:US
Practice Address - Phone:763-710-9937
Practice Address - Fax:763-710-9968
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-22
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND129601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1356749659Medicaid
MN1174913339Medicaid