Provider Demographics
NPI:1619604469
Name:BODUNDE, DEBORAH OLUWAKEMI
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:OLUWAKEMI
Last Name:BODUNDE
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 1:1596 HIGHLAND STREET
Mailing Address - Street 2:APT E
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201
Mailing Address - Country:US
Mailing Address - Phone:614-589-2203
Mailing Address - Fax:
Practice Address - Street 1:305 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-688-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-04-03
Deactivation Date:2023-03-13
Deactivation Code:
Reactivation Date:2023-04-03
Provider Licenses
StateLicense IDTaxonomies
OHRES.0044991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics