Healthcare Provider Details

I. General information

NPI: 1740572841
Provider Name (Legal Business Name): OLUREMI OGUNSANYA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 E 19TH ST STE 1
BROOKLYN NY
11229-1375
US

IV. Provider business mailing address

3273 PARKSIDE PL APT 2C
BRONX NY
10467-4931
US

V. Phone/Fax

Practice location:
  • Phone: 718-576-6999
  • Fax:
Mailing address:
  • Phone: 646-769-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number058374-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: