Healthcare Provider Details

I. General information

NPI: 1891873899
Provider Name (Legal Business Name): OLUFEMI A OGUNTOLU D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 SQUIRE RD
REVERE MA
02151-4311
US

IV. Provider business mailing address

252 SQUIRE RD
REVERE MA
02151-4311
US

V. Phone/Fax

Practice location:
  • Phone: 781-286-1620
  • Fax: 781-289-7901
Mailing address:
  • Phone: 781-286-1620
  • Fax: 781-289-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19363
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: