Provider Demographics
NPI:1417444332
Name:OKORUWA, EBOSETALE ODIAOGBE (DDS)
Entity Type:Individual
Prefix:DR
First Name:EBOSETALE
Middle Name:ODIAOGBE
Last Name:OKORUWA
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 1:2052 IRENE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6613
Mailing Address - Country:US
Mailing Address - Phone:712-309-6588
Mailing Address - Fax:
Practice Address - Street 1:6936 PINE ARBOR DR S STE 230
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4645
Practice Address - Country:US
Practice Address - Phone:651-204-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002470122300000X
390200000X
MND14478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program