MEDICARE: ABIDEMI GBOTOSHO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0026015	TX
2	122300000X	Dentist	019029289	IL

General Provider Information

NPI Number	:	1205145976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIDEMI GBOTOSHO DDS

Provider Business Mailing Address
First Line	:	1650 S ALBANY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-2251
Country	:	US
Telephone Number	:	347-416-3147
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 S ALBANY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-2251
Country	:	US
Telephone Number	:	347-416-3147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	04/23/2021

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Directions to “ ABIDEMI GBOTOSHO DDS” Practice Location

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