Provider Demographics
NPI:1699397984
Name:ONWUKWE, EDMOND EBUBECHUKWU
Entity Type:Individual
Prefix:MISS
First Name:EDMOND
Middle Name:EBUBECHUKWU
Last Name:ONWUKWE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3444
Mailing Address - Country:US
Mailing Address - Phone:301-768-9678
Mailing Address - Fax:
Practice Address - Street 1:11212 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4476
Practice Address - Country:US
Practice Address - Phone:502-742-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0271101223E0200X
CA390200000X
KY109891223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program