Provider Demographics
NPI:1649574203
Name:AWOFOLU, OMOTENIOLA DESIREE (DDS)
Entity Type:Individual
Prefix:
First Name:OMOTENIOLA
Middle Name:DESIREE
Last Name:AWOFOLU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 PROMENADE PL
Mailing Address - Street 2:APT 205
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:443-928-3783
Mailing Address - Fax:
Practice Address - Street 1:7651 MATAPEAKE BUSINESS DRIVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-4551
Practice Address - Country:US
Practice Address - Phone:301-542-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD149291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice