Provider Demographics
NPI:1952078685
Name:OKOLI, IFEANYI (DDS)
Entity Type:Individual
Prefix:
First Name:IFEANYI
Middle Name:
Last Name:OKOLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15041 119TH RD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2001
Mailing Address - Country:US
Mailing Address - Phone:347-320-5856
Mailing Address - Fax:
Practice Address - Street 1:2180 MACARTHUR RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-4535
Practice Address - Country:US
Practice Address - Phone:610-437-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0438131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program