Provider Demographics
NPI:1326704693
Name:ITAGEGNEHOU GEDAMU DMD PLLC
Entity Type:Organization
Organization Name:ITAGEGNEHOU GEDAMU DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ITAGEGNEHOU
Authorized Official - Middle Name:
Authorized Official - Last Name:GEDAMU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-785-9620
Mailing Address - Street 1:PO BOX 70887
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44190-0887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20991 ARSENAL STREET RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4552
Practice Address - Country:US
Practice Address - Phone:315-785-9620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-11
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty