Provider Demographics
NPI:1033314216
Name:OLAGBEMI, IBUKUN O
Entity Type:Individual
Prefix:
First Name:IBUKUN
Middle Name:O
Last Name:OLAGBEMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1900
Mailing Address - Country:US
Mailing Address - Phone:717-545-7400
Mailing Address - Fax:
Practice Address - Street 1:1199 COLONIAL RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-1900
Practice Address - Country:US
Practice Address - Phone:717-545-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0374531223E0200X
MA212941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice