Provider Demographics
NPI:1205388287
Name:CHUKWUKA, IFEANYI (DDS)
Entity Type:Individual
Prefix:
First Name:IFEANYI
Middle Name:
Last Name:CHUKWUKA
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 1:554 KEILY STREET
Mailing Address - Street 2:BUREAU OF MEDICINE AND SURGERY - CCPD
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:23321
Mailing Address - Country:US
Mailing Address - Phone:757-953-1897
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:BUREAU OF MEDICINE AND SURGERY - CCPD
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:23321
Practice Address - Country:US
Practice Address - Phone:757-953-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist