Healthcare Provider Details

I. General information

NPI: 1902358385
Provider Name (Legal Business Name): OLUSOLA SOWUNMI RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 FORT EVANS RD NE
LEESBURG VA
20176-4420
US

IV. Provider business mailing address

163 FORT EVANS RD NE
LEESBURG VA
20176-4420
US

V. Phone/Fax

Practice location:
  • Phone: 703-840-4705
  • Fax: 703-771-4120
Mailing address:
  • Phone: 703-840-4705
  • Fax: 703-771-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402206994
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: