Provider Demographics
NPI:1205145976
Name:GBOTOSHO, ABIDEMI (DDS)
Entity type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:
Last Name:GBOTOSHO
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 1:1650 S ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2251
Mailing Address - Country:US
Mailing Address - Phone:347-416-3147
Mailing Address - Fax:
Practice Address - Street 1:1650 S ALBANY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2251
Practice Address - Country:US
Practice Address - Phone:347-416-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00260151223G0001X
IL019029289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice