Healthcare Provider Details

I. General information

NPI: 1700044781
Provider Name (Legal Business Name): AMANDA JO OKUNDAYE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11970 MONTANA AVE APT 208
LOS ANGELES CA
90049-5043
US

IV. Provider business mailing address

3815 TROPICAL VINE ST
LAS VEGAS NV
89147-8079
US

V. Phone/Fax

Practice location:
  • Phone: 310-486-6656
  • Fax: 424-208-3232
Mailing address:
  • Phone: 310-486-6656
  • Fax: 866-235-3806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number56779
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number56779
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number5993
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: