Provider Demographics
NPI:1679197917
Name:MOWOBI, ADELEKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ADELEKE
Middle Name:
Last Name:MOWOBI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W GRENSHAW ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1042
Mailing Address - Country:US
Mailing Address - Phone:619-847-1746
Mailing Address - Fax:
Practice Address - Street 1:1 ADMINISTRATION CIR
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-6104
Practice Address - Country:US
Practice Address - Phone:760-939-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032621122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist