Provider Demographics
NPI:1316367352
Name:FATOGUN, OLUWATOYIN MORENIKE (DDS)
Entity Type:Individual
Prefix:
First Name:OLUWATOYIN
Middle Name:MORENIKE
Last Name:FATOGUN
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 1:2221 E BIJOU ST STE 1002221E
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8008
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:6725 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:LANDOVER HILLS
Practice Address - State:MD
Practice Address - Zip Code:20784-1904
Practice Address - Country:US
Practice Address - Phone:301-773-4746
Practice Address - Fax:301-773-4941
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD157631223G0001X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC070533400Medicaid
MD110636800Medicaid