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General NPI Number Information
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NPI Number | 1164945150
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Entity Type | Individual
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Provider Name | OLUWADAMILOLA OMODELE AJAGBE DDS
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Gender | Female
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Dates
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Enumeration Date | 07/21/2017
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Last Update Date | 12/13/2024
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Provider Practice Location Address
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Address Line | 44 SAINT CROIX TRL S STE 100
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City | LAKELAND
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State | MN
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Zip | 55043-9657
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Country | US
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Telephone | 651-436-5177
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Fax |
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Provider Business Mailing Address
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Address Line | 2817 S COOPER ST APT 2311
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City | ARLINGTON
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State | TX
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Zip | 76015-2465
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 34948
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D13899
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License Number State | MN
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