Provider Demographics
NPI:1669781274
Name:IDAHOSA, CHIZOBAM NKIRU (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:CHIZOBAM
Middle Name:NKIRU
Last Name:IDAHOSA
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:CHIZOBAM
Other - Middle Name:NKIRU
Other - Last Name:UNACHUKWU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1303
Mailing Address - Country:US
Mailing Address - Phone:267-984-2757
Mailing Address - Fax:
Practice Address - Street 1:240 S 40TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6030
Practice Address - Country:US
Practice Address - Phone:215-898-8965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2023-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0386571223G0001X, 1223X2210X, 125Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125Q00000XDental ProvidersDentistOral Medicine
No1223G0001XDental ProvidersDentistGeneral Practice
No1223X2210XDental ProvidersDentistOrofacial Pain