Provider Demographics
NPI:1164043410
Name:ODUTOLA, OLUWASEUN
Entity Type:Individual
Prefix:DR
First Name:OLUWASEUN
Middle Name:
Last Name:ODUTOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4754 COMMERCIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-6205
Mailing Address - Country:US
Mailing Address - Phone:315-768-7799
Mailing Address - Fax:
Practice Address - Street 1:4754 COMMERCIAL DR STE 2
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-6205
Practice Address - Country:US
Practice Address - Phone:315-768-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY062186122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8131455OtherUNITEDHEALTHCARE STUDENT RESOURCES