Provider Demographics
NPI:1497288575
Name:MKOROMBINDO, EUDORA
Entity Type:Individual
Prefix:
First Name:EUDORA
Middle Name:
Last Name:MKOROMBINDO
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 1:231 ALBERT SABIN WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45267-0769
Mailing Address - Country:US
Mailing Address - Phone:513-584-6660
Mailing Address - Fax:513-584-6661
Practice Address - Street 1:3098 ALLISON BONNETT MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HUEYTOWN
Practice Address - State:AL
Practice Address - Zip Code:35023-2233
Practice Address - Country:US
Practice Address - Phone:205-491-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALAL0006578-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program