=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629466511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLAJUMOKE ADEDOYIN, DDS OF LOUISIANA, A PROFESSIONAL DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2014
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1128 PECANLAND RD STE 1
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-7019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-450-3104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1128 PECANLAND RD STE 1
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-7019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-450-3104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT MANAGER
-----------------------------------------------------
Name | HALEY WOOSTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 984-251-8846
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6219
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------