Provider Demographics
NPI:1922187517
Name:OKUMU DENTAL CENTER, PC
Entity Type:Organization
Organization Name:OKUMU DENTAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:OKUMU
Authorized Official - Last Name:NGAJI-OKUMU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-466-9545
Mailing Address - Street 1:1131 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-3518
Mailing Address - Country:US
Mailing Address - Phone:610-466-9545
Mailing Address - Fax:610-466-9545
Practice Address - Street 1:1131 OLIVE ST
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-3518
Practice Address - Country:US
Practice Address - Phone:610-466-9545
Practice Address - Fax:610-466-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036492261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018743640002Medicaid
PADS036492OtherDENTIST LICENSE