Healthcare Provider Details

I. General information

NPI: 1659796761
Provider Name (Legal Business Name): OLUTOYIN AGBELEMOSE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4458 JONESBORO RD
FOREST PARK GA
30297-4314
US

IV. Provider business mailing address

790 GLENWOOD AVE SE STE 210
ATLANTA GA
30316-2024
US

V. Phone/Fax

Practice location:
  • Phone: 470-878-3512
  • Fax:
Mailing address:
  • Phone: 404-260-4767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN123224
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123224
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: