Provider Demographics
NPI:1801148457
Name:KINGSLEY MOMODU, DDS & ASSOCIATES, PLLC
Entity type:Organization
Organization Name:KINGSLEY MOMODU, DDS & ASSOCIATES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTAL SURGEON/PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KINGSLEY
Authorized Official - Middle Name:OISE
Authorized Official - Last Name:MOMODU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-762-1987
Mailing Address - Street 1:2901 BREEZEWOOD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5409
Mailing Address - Country:US
Mailing Address - Phone:443-762-1987
Mailing Address - Fax:
Practice Address - Street 1:2901 BREEZEWOOD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5409
Practice Address - Country:US
Practice Address - Phone:443-762-1987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-06
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC#9234261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental