Provider Demographics
NPI:1215240072
Name:AKINYEDE, IBUKUN T (DDS)
Entity type:Individual
Prefix:DR
First Name:IBUKUN
Middle Name:T
Last Name:AKINYEDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-323-0423
Mailing Address - Fax:573-323-8931
Practice Address - Street 1:215 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638-0157
Practice Address - Country:US
Practice Address - Phone:573-323-0423
Practice Address - Fax:573-323-8931
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028433122300000X
MO20110173431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1215240072Medicaid