Provider Demographics
NPI:1073688818
Name:KOLE-JAMES, KISHAWN OLASUPO (DDS)
Entity Type:Individual
Prefix:DR
First Name:KISHAWN
Middle Name:OLASUPO
Last Name:KOLE-JAMES
Suffix:
Gender:M
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:PO BOX 2879
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-0879
Mailing Address - Country:US
Mailing Address - Phone:313-282-5651
Mailing Address - Fax:
Practice Address - Street 1:1799 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-3145
Practice Address - Country:US
Practice Address - Phone:313-282-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010194441223G0001X
MI194441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4935200Medicaid