Provider Demographics
NPI:1407629173
Name:AVALON DENTAL CENTER, INC
Entity Type:Organization
Organization Name:AVALON DENTAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOFOLUSARA
Authorized Official - Middle Name:O
Authorized Official - Last Name:OGUNFUSIKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-599-0404
Mailing Address - Street 1:9614 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3670
Mailing Address - Country:US
Mailing Address - Phone:301-599-0404
Mailing Address - Fax:301-599-1620
Practice Address - Street 1:9614 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3670
Practice Address - Country:US
Practice Address - Phone:301-599-0404
Practice Address - Fax:301-599-1620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental