Healthcare Provider Details

I. General information

NPI: 1215240072
Provider Name (Legal Business Name): IBUKUN T AKINYEDE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 WALNUT STREET
ELLINGTON MO
63638-0157
US

IV. Provider business mailing address

PO BOX 157
ELLINGTON MO
63638-0157
US

V. Phone/Fax

Practice location:
  • Phone: 573-323-0423
  • Fax: 573-323-8931
Mailing address:
  • Phone: 573-323-0423
  • Fax: 573-323-8931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019028433
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2011017343
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: