Provider Demographics
NPI:1831170042
Name:OGUNDARE, BOLAJI OLUSOLA (DDS)
Entity type:Individual
Prefix:DR
First Name:BOLAJI
Middle Name:OLUSOLA
Last Name:OGUNDARE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 1ST AVE
Mailing Address - Street 2:SUITE 9QQ
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-5677
Mailing Address - Fax:212-263-6931
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SUITE 9QQ
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5677
Practice Address - Fax:212-263-6931
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048685-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU94841Medicare UPIN