Provider Demographics
NPI:1811446644
Name:KOFOWOROLA-KUTI, ANTHONY OLULAJA OLAYIWOLA (DMD,MPH,BDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:OLULAJA OLAYIWOLA
Last Name:KOFOWOROLA-KUTI
Suffix:
Gender:M
Credentials:DMD,MPH,BDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3002 PAXTON HILLS LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-4061
Mailing Address - Country:US
Mailing Address - Phone:336-354-9314
Mailing Address - Fax:
Practice Address - Street 1:21434 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7587
Practice Address - Country:US
Practice Address - Phone:281-398-4369
Practice Address - Fax:281-398-4328
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX324321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice