Provider Demographics
NPI:1184911240
Name:OLUWADARA, OLUWADAYO O (MS, PHD, DDS)
Entity type:Individual
Prefix:
First Name:OLUWADAYO
Middle Name:O
Last Name:OLUWADARA
Suffix:
Gender:M
Credentials:MS, PHD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9612 FOOTHILL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3594
Mailing Address - Country:US
Mailing Address - Phone:909-939-5569
Mailing Address - Fax:909-354-3230
Practice Address - Street 1:9612 FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3594
Practice Address - Country:US
Practice Address - Phone:909-939-5569
Practice Address - Fax:909-354-3230
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX274531223G0001X
CA1012351223G0001X
WI6775-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284941617Medicaid