Healthcare Provider Details

I. General information

NPI: 1962058552
Provider Name (Legal Business Name): OLUMIDE TOLUWALOPE OLOWOKERE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2019
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 ARAPAHO AVE STE B
SPRINGDALE AR
72764-6939
US

IV. Provider business mailing address

6128 W PLEASANT DR
ROGERS AR
72758-9556
US

V. Phone/Fax

Practice location:
  • Phone: 479-488-3269
  • Fax:
Mailing address:
  • Phone: 205-276-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4703
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35595
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: