Provider Demographics
NPI:1790187128
Name:OLALEKAN OKUNUGA, DDS, P.C.
Entity Type:Organization
Organization Name:OLALEKAN OKUNUGA, DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-744-4529
Mailing Address - Street 1:1165 E ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-9547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1165 E ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-9547
Practice Address - Country:US
Practice Address - Phone:434-447-2492
Practice Address - Fax:434-447-2873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty