Provider Demographics
NPI:1376983908
Name:JOLAOSO, ISMAIL ADEYEMI (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:ISMAIL
Middle Name:ADEYEMI
Last Name:JOLAOSO
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1846
Mailing Address - Country:US
Mailing Address - Phone:413-528-5565
Mailing Address - Fax:
Practice Address - Street 1:343 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1846
Practice Address - Country:US
Practice Address - Phone:413-528-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL12333122300000X
VA0401414551122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health