Provider Demographics
NPI:1356398556
Name:NGAJI-OKUMU, WALTER OKUMU (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:OKUMU
Last Name:NGAJI-OKUMU
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 1:13 BUCK RUN LANE
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1609
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
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13418122300000X
MI2901018732122300000X
PADS0364921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013486250005Medicaid
PA1013486250001Medicaid