Provider Demographics
NPI:1043842214
Name:FUNPEDOPARK LLC
Entity Type:Organization
Organization Name:FUNPEDOPARK LLC
Other - Org Name:FUN PARK PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLANREWAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:OYE-SOMEFUN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-767-7275
Mailing Address - Street 1:1009 CENTERBROOKE LN STE 210
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8664
Mailing Address - Country:US
Mailing Address - Phone:757-767-7275
Mailing Address - Fax:
Practice Address - Street 1:1009 CENTERBROOKE LN STE 210
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8664
Practice Address - Country:US
Practice Address - Phone:757-767-7275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401416127OtherDENTAL LICENSE