Healthcare Provider Details

I. General information

NPI: 1063083301
Provider Name (Legal Business Name): ADETOKUNBO OLAWUYI BDS, DMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 SAINT JOHNS BLVD
JOPLIN MO
64804-1598
US

IV. Provider business mailing address

907 NORTH MAIN STREET
WEBB CITY MO
64870
US

V. Phone/Fax

Practice location:
  • Phone: 240-714-7435
  • Fax:
Mailing address:
  • Phone: 240-714-7435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number2025024708
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: