Provider Demographics
NPI:1740298371
Name:OGUNFUSIKA, MOFOLUSARA O (DDS)
Entity type:Individual
Prefix:
First Name:MOFOLUSARA
Middle Name:O
Last Name:OGUNFUSIKA
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 1:9614 MARLBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3670
Mailing Address - Country:US
Mailing Address - Phone:301-599-0404
Mailing Address - Fax:301-599-0400
Practice Address - Street 1:9614 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3670
Practice Address - Country:US
Practice Address - Phone:301-599-0404
Practice Address - Fax:301-599-0400
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13036122300000X
DCDEN1000990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDEN1000990OtherDENTAL LICENSE
MD9181182OtherDORAL DENTAL