Provider Demographics
NPI:1467616268
Name:JOHNSON, OLAKUNLE I
Entity Type:Individual
Prefix:DR
First Name:OLAKUNLE
Middle Name:I
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 JAIME ZAPATA MEMORIAL HIGHWAY
Mailing Address - Street 2:SUITE A6
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043
Mailing Address - Country:US
Mailing Address - Phone:956-727-8200
Mailing Address - Fax:956-727-8202
Practice Address - Street 1:5300 SAN DARIO AVE # C-2
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-3000
Practice Address - Country:US
Practice Address - Phone:956-723-6568
Practice Address - Fax:678-904-5666
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX240291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice