Healthcare Provider Details

I. General information

NPI: 1497903280
Provider Name (Legal Business Name): OLALEKAN IDOWU OKUNUGA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2735 N BLACKSTONE AVE
FRESNO CA
93703-1705
US

IV. Provider business mailing address

2735 N BLACKSTONE AVE
FRESNO CA
93703-1705
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-3391
  • Fax: 559-225-1601
Mailing address:
  • Phone: 559-225-3391
  • Fax: 559-225-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: