Provider Demographics
NPI:1336554906
Name:EZEJA, EJIKE BARTHOLOMEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:EJIKE
Middle Name:BARTHOLOMEW
Last Name:EZEJA
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 1:1159 FIFIELD AVE
Mailing Address - Street 2:APT. N4
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1108
Mailing Address - Country:US
Mailing Address - Phone:612-598-3786
Mailing Address - Fax:
Practice Address - Street 1:1609 NORMAN RD STE B
Practice Address - Street 2:ASPEN DENTAL
Practice Address - City:SAINT PAUL
Practice Address - State:GA
Practice Address - Zip Code:31601-4201
Practice Address - Country:US
Practice Address - Phone:229-269-4607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014878122300000X
MND13431122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist