Healthcare Provider Details

I. General information

NPI: 1821492505
Provider Name (Legal Business Name): OLUTAYO A. ODUSANWO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 PRAIRIE AVE
PROVIDENCE RI
02905
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0430
  • Fax: 401-444-0489
Mailing address:
  • Phone: 401-444-0400
  • Fax: 401-444-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1856580
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN03469
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: