Provider Demographics
NPI:1659796761
Name:AGBELEMOSE, OLUTOYIN (DDS)
Entity Type:Individual
Prefix:
First Name:OLUTOYIN
Middle Name:
Last Name:AGBELEMOSE
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 1:790 GLENWOOD AVE SE STE 210
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2024
Mailing Address - Country:US
Mailing Address - Phone:404-260-4767
Mailing Address - Fax:
Practice Address - Street 1:790 GLENWOOD AVE SE STE 210
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2024
Practice Address - Country:US
Practice Address - Phone:404-260-4767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
GADN123224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator