Provider Demographics
NPI:1558699744
Name:ADONAI DENTAL CLINIC
Entity Type:Organization
Organization Name:ADONAI DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAKUNLE
Authorized Official - Middle Name:IBITOYE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-918-5942
Mailing Address - Street 1:3210 LOOP 20
Mailing Address - Street 2:#A6
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-5009
Mailing Address - Country:US
Mailing Address - Phone:956-727-8200
Mailing Address - Fax:
Practice Address - Street 1:3210 LOOP 20
Practice Address - Street 2:#A6
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-5009
Practice Address - Country:US
Practice Address - Phone:956-727-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-26
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX240291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1467616268Medicaid