Provider Demographics
NPI:1164945150
Name:AJAGBE, OLUWADAMILOLA OMODELE (DDS)
Entity Type:Individual
Prefix:
First Name:OLUWADAMILOLA
Middle Name:OMODELE
Last Name:AJAGBE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922B MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-2321
Mailing Address - Country:US
Mailing Address - Phone:214-426-3645
Mailing Address - Fax:214-426-3645
Practice Address - Street 1:2922B MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-2321
Practice Address - Country:US
Practice Address - Phone:214-426-3645
Practice Address - Fax:507-424-1040
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13899122300000X
TX349481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND13899OtherMINNESOTA BOARD OF DENTISTRY
TX34948OtherTEXAS BOARD OF DENTAL EXAMINERS