Healthcare Provider Details

I. General information

NPI: 1437644549
Provider Name (Legal Business Name): MODUPE MARY OGUNNUSI SOFUYE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2018
Last Update Date: 06/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 E IRELAND RD
SOUTH BEND IN
46614-3474
US

IV. Provider business mailing address

823B SORIN ST
SOUTH BEND IN
46617-2047
US

V. Phone/Fax

Practice location:
  • Phone: 574-299-1400
  • Fax:
Mailing address:
  • Phone: 786-619-4170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12012973A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: