Provider Demographics
NPI:1780989822
Name:DEREK C. EGO-OSUALA LLC
Entity type:Organization
Organization Name:DEREK C. EGO-OSUALA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:EGO-OSUALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:240-244-1013
Mailing Address - Street 1:7700 OLD BRANCH AVE
Mailing Address - Street 2:A-204
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1628
Mailing Address - Country:US
Mailing Address - Phone:240-244-1013
Mailing Address - Fax:240-244-1035
Practice Address - Street 1:7700 OLD BRANCH AVENUE
Practice Address - Street 2:A-204
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:240-244-1013
Practice Address - Fax:240-244-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD141621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty