Provider Demographics
NPI:1417379777
Name:OMOTENIOLA AWOFOLU DDS. LLC
Entity type:Organization
Organization Name:OMOTENIOLA AWOFOLU DDS. LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OMOTENIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWOFOLU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-525-0555
Mailing Address - Street 1:3407 WILKENS AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5072
Mailing Address - Country:US
Mailing Address - Phone:410-525-0555
Mailing Address - Fax:410-525-1055
Practice Address - Street 1:3407 WILKENS AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5072
Practice Address - Country:US
Practice Address - Phone:410-525-0555
Practice Address - Fax:410-525-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD051736400Medicaid