Provider Demographics
NPI:1598186132
Name:OLU OYEGUNWA DDS PA
Entity Type:Organization
Organization Name:OLU OYEGUNWA DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLU
Authorized Official - Middle Name:AYOOLA
Authorized Official - Last Name:OYEGUNWA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-484-5141
Mailing Address - Street 1:3416 MELROSE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3416 MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1610
Practice Address - Country:US
Practice Address - Phone:910-484-5141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-28
Last Update Date:2013-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9306261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942561634Medicaid