Provider Demographics
NPI:1356570998
Name:EZEANOLUE, BIBIANA CHIOMA (DMD)
Entity type:Individual
Prefix:DR
First Name:BIBIANA
Middle Name:CHIOMA
Last Name:EZEANOLUE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 WHEELER PEAK DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2150
Mailing Address - Country:US
Mailing Address - Phone:702-272-1100
Mailing Address - Fax:702-998-0675
Practice Address - Street 1:1750 WHEELER PEAK DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2150
Practice Address - Country:US
Practice Address - Phone:702-272-1100
Practice Address - Fax:702-998-0675
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL15962141223P0221X
TX28621122300000X
NVS6-118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1356570998Medicaid