Healthcare Provider Details

I. General information

NPI: 1396123352
Provider Name (Legal Business Name): OLUWOLE OLUBUNMI FADAHUNSI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 09/15/2022
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7611 LITTLE RIVER TPKE STE 101E
ANNANDALE VA
22003-2630
US

IV. Provider business mailing address

7611 LITTLE RIVER TPKE STE 101E
ANNANDALE VA
22003-2630
US

V. Phone/Fax

Practice location:
  • Phone: 703-634-4195
  • Fax:
Mailing address:
  • Phone: 703-634-4195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16193
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN1001975
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2019016472
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19032524
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401416435
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: