Healthcare Provider Details

I. General information

NPI: 1174829576
Provider Name (Legal Business Name): KEHINDE ADETORO OGUNDELE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4124 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4317
US

IV. Provider business mailing address

6100 CITY AVE APT# 502
PHILADELPHIA PA
19131-1239
US

V. Phone/Fax

Practice location:
  • Phone: 904-733-3763
  • Fax: 904-733-9783
Mailing address:
  • Phone: 818-675-4686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22261
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: