Provider Demographics
NPI:1902449325
Name:FUNMI ABOSEDE
Entity type:Organization
Organization Name:FUNMI ABOSEDE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FUNMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOSEDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:312-498-9323
Mailing Address - Street 1:3809 S CONGRESS AVE APT 447
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-8035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:424 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-3018
Practice Address - Country:US
Practice Address - Phone:361-552-2977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-18
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty