Provider Demographics
NPI:1477304111
Name:IWUCHUKWU, AFAMDI O (DENTAL STUDENT)
Entity Type:Individual
Prefix:
First Name:AFAMDI
Middle Name:O
Last Name:IWUCHUKWU
Suffix:
Gender:M
Credentials:DENTAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 DALRYMPLE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-5064
Mailing Address - Country:US
Mailing Address - Phone:209-652-0656
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:209-788-9282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program