Provider Demographics
NPI:1467660860
Name:IBITAYO, ADEBIMPE (DDS, MS)
Entity Type:Individual
Prefix:
First Name:ADEBIMPE
Middle Name:
Last Name:IBITAYO
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ROSE GDN
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3422
Mailing Address - Country:US
Mailing Address - Phone:210-658-2251
Mailing Address - Fax:
Practice Address - Street 1:106 ROSE GDN
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3422
Practice Address - Country:US
Practice Address - Phone:210-658-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019446122300000X
TX250031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist