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General NPI Number Information
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NPI Number | 1962029934
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Entity Type | Individual
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Provider Name | ABISOLA JEGEDE DMD, MPH
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Gender | Female
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Dates
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Enumeration Date | 06/25/2020
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Last Update Date | 08/20/2025
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Provider Practice Location Address
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Address Line | 919 E JEFFERSON BLVD STE 100
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City | SOUTH BEND
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State | IN
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Zip | 46617-3112
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Country | US
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Telephone | 574-245-7504
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Fax |
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Provider Business Mailing Address
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Address Line | 3411 NELSON RD STE 100
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City | LAKE CHARLES
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State | LA
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Zip | 70605-1240
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 7109
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12014860A
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License Number State | IN
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