Provider Demographics
NPI:1851089023
Name:ANIWIGBO, CHIOMA JESSICA
Entity Type:Individual
Prefix:
First Name:CHIOMA
Middle Name:JESSICA
Last Name:ANIWIGBO
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 1:2216 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2944
Mailing Address - Country:US
Mailing Address - Phone:909-392-3899
Mailing Address - Fax:
Practice Address - Street 1:2216 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2944
Practice Address - Country:US
Practice Address - Phone:909-392-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist