Healthcare Provider Details

I. General information

NPI: 1508418088
Provider Name (Legal Business Name): AYOMIDE OGUNYE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIDE OGUNYE DDS

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7324 GASTON AVE STE 121
DALLAS TX
75214-6159
US

IV. Provider business mailing address

7324 GASTON AVE STE 121
DALLAS TX
75214-6159
US

V. Phone/Fax

Practice location:
  • Phone: 469-917-0418
  • Fax:
Mailing address:
  • Phone: 469-917-0418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36169
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number36160
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: