MEDICARE: DR. OLUWASEUN OLUMIDE FASOYIRO

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	D14785	MN

General Provider Information

NPI Number	:	1427787415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLUWASEUN OLUMIDE FASOYIRO

Provider Business Mailing Address
First Line	:	413 MANGROVE LN
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-6503
Country	:	US
Telephone Number	:	716-348-2654
Fax Number	:

Provider Business Practice Location Address
First Line	:	1290 SALEM RD SW STE 10
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55902-4210
Country	:	US
Telephone Number	:	402-617-7862
Fax Number	:

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

Provider Enumeration Date	:	06/07/2022
Last Update Date	:	07/07/2022

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