Provider Demographics
NPI:1114661154
Name:ORESANYA, OLUWATOYIN ABOSEDE
Entity Type:Individual
Prefix:
First Name:OLUWATOYIN
Middle Name:ABOSEDE
Last Name:ORESANYA
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 1:287 SHAW DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2075
Mailing Address - Country:US
Mailing Address - Phone:470-313-0894
Mailing Address - Fax:
Practice Address - Street 1:1680 E WEST CONNECTOR STE 112
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1241
Practice Address - Country:US
Practice Address - Phone:770-742-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist