Provider Demographics
NPI:1164591913
Name:FAWOLE, SUNDAY A (DDS, MD)
Entity Type:Individual
Prefix:
First Name:SUNDAY
Middle Name:A
Last Name:FAWOLE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 SCENIC HWY S
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3134
Mailing Address - Country:US
Mailing Address - Phone:678-377-6830
Mailing Address - Fax:678-377-6836
Practice Address - Street 1:2395 SCENIC HWY S
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3134
Practice Address - Country:US
Practice Address - Phone:678-377-6830
Practice Address - Fax:678-377-6836
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55514207QA0505X
GADNO126981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA586073644EMedicaid