Ikechukwu P. Ebo, D.D.S., P.A.

Primary specialty

DentistTaxonomy code 122300000X

License

DN013673 Issued in GA

Practice address

650 Gwinnett Dr
Lawrenceville, GA 30046-7439

Phone

(770) 963-5999

Fax

(770) 963-6603

NPI assigned

Nov 22, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164153600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1309478400000",
    "number": "1093880288",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "650 GWINNETT DR.",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "30045",
            "telephone_number": "770-963-5999",
            "fax_number": "770-963-6603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "650 GWINNETT DR",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300467439",
            "telephone_number": "770-963-5999",
            "fax_number": "770-963-6603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "EBO",
        "first_name": "IKECHUKWU",
        "middle_name": "P.",
        "name_prefix": "Dr.",
        "credential": "D.D.S., P.A.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-11-22",
        "last_updated": "2011-07-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "GA",
            "license": "DN013673",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NC",
            "license": "7427",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "89902F3",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5901375",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Lawrenceville, GA
• Providers in Lawrenceville, GA by specialty
• Dentist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.