Provider Demographics
NPI:1720489578
Name:OSUNDEKO, JESUTOFUNMI (DMD)
Entity type:Individual
Prefix:
First Name:JESUTOFUNMI
Middle Name:
Last Name:OSUNDEKO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 FREEDOM LN NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4761
Mailing Address - Country:US
Mailing Address - Phone:360-339-4373
Mailing Address - Fax:
Practice Address - Street 1:8050 FREEDOM LN NE
Practice Address - Street 2:SUITE C
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4761
Practice Address - Country:US
Practice Address - Phone:360-339-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60574855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist