Provider Demographics
NPI:1417696147
Name:OBI, CHIDIOGO
Entity Type:Individual
Prefix:
First Name:CHIDIOGO
Middle Name:
Last Name:OBI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 OAK ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 ROE BLVD
Practice Address - Street 2:
Practice Address - City:ROELAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66205-2390
Practice Address - Country:US
Practice Address - Phone:913-828-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty