Provider Demographics
NPI:1265144869
Name:FAKUNLE, TAIWO SEMILORE
Entity type:Individual
Prefix:
First Name:TAIWO
Middle Name:SEMILORE
Last Name:FAKUNLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:US ARMY DENTAL ACTIVITY, 6958 NEBRASKA AVE
Mailing Address - Street 2:BLDG 1608
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9223
Mailing Address - Country:US
Mailing Address - Phone:573-596-0408
Mailing Address - Fax:
Practice Address - Street 1:US ARMY DENTAL ACTIVITY 6958 NEBRASKA AVE
Practice Address - Street 2:BLDG 1608
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9223
Practice Address - Country:US
Practice Address - Phone:573-596-0408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist