Provider Demographics
NPI:1013682244
Name:UKAEGBU, KELECHI
Entity Type:Individual
Prefix:DR
First Name:KELECHI
Middle Name:
Last Name:UKAEGBU
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 1:1500 JACKSON ST APT 802
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3302 GASTON AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2013
Practice Address - Country:US
Practice Address - Phone:972-799-6706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40052122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentistGroup - Single Specialty