Provider Demographics
NPI:1033145628
Name:ADETONA, OMOLOLA (DDS)
Entity Type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:
Last Name:ADETONA
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 1:9480 HUEBNER RD
Mailing Address - Street 2:#400
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1655
Mailing Address - Country:US
Mailing Address - Phone:210-697-3900
Mailing Address - Fax:210-697-3904
Practice Address - Street 1:9480 HUEBNER RD
Practice Address - Street 2:#400
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1655
Practice Address - Country:US
Practice Address - Phone:210-697-3900
Practice Address - Fax:210-697-3904
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21908OtherTEXAS DENTAL LICENSE
TX281602701Medicaid