Provider Demographics
NPI:1528622735
Name:OMOLE, DAVID OLATUNJI (DDS)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:OLATUNJI
Last Name:OMOLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 N WALDRON ST.
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502
Mailing Address - Country:US
Mailing Address - Phone:620-663-1141
Mailing Address - Fax:620-663-1373
Practice Address - Street 1:2301 N WALDRON ST.
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502
Practice Address - Country:US
Practice Address - Phone:620-663-1141
Practice Address - Fax:620-663-1373
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2024-08-09
Deactivation Date:2019-12-09
Deactivation Code:
Reactivation Date:2020-01-28
Provider Licenses
StateLicense IDTaxonomies
ZZ117025122300000X
KS621701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist