Provider Demographics
NPI:1609496637
Name:BAMGBADE, BERNICE ADERINTOLA
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:ADERINTOLA
Last Name:BAMGBADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 EL PASEO ST APT 512
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-3045
Mailing Address - Country:US
Mailing Address - Phone:713-401-8925
Mailing Address - Fax:
Practice Address - Street 1:1015 DONALD LEE HOLLOWELL PKWY NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-6653
Practice Address - Country:US
Practice Address - Phone:404-523-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX390181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program