Provider Demographics
NPI:1225309362
Name:PATRICK, YETUNDE IBIYEMI (DDS)
Entity Type:Individual
Prefix:DR
First Name:YETUNDE
Middle Name:IBIYEMI
Last Name:PATRICK
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 1:1515 U STREET NW SUITE A1 C-1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009
Mailing Address - Country:US
Mailing Address - Phone:202-900-9006
Mailing Address - Fax:
Practice Address - Street 1:1515 U ST NW STE A-1C1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-3948
Practice Address - Country:US
Practice Address - Phone:202-900-9006
Practice Address - Fax:202-900-8980
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD150031223G0001X
DCDEN1001234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD052089600Medicaid