Healthcare Provider Details

I. General information

NPI: 1407415870
Provider Name (Legal Business Name): BOLADE OGUNRINDE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 E GIBSON ST
JASPER TX
75951-5028
US

IV. Provider business mailing address

17214 QUIET COVEY CT
MISSOURI CITY TX
77489-6156
US

V. Phone/Fax

Practice location:
  • Phone: 281-414-4842
  • Fax:
Mailing address:
  • Phone: 516-800-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36007
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: