Healthcare Provider Details

I. General information

NPI: 1336592682
Provider Name (Legal Business Name): ADEKUNLE BUKOLA AJAYI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 W BEACH AVE APT 101
INGLEWOOD CA
90302-7306
US

IV. Provider business mailing address

4101 BRITTANY ST APT 206
BAKERSFIELD CA
93312-2368
US

V. Phone/Fax

Practice location:
  • Phone: 734-029-8777
  • Fax:
Mailing address:
  • Phone: 773-402-9878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number101954
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: