MEDICARE: BUKOLA ODUYELU, DDS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	0401008828	VA

General Provider Information

NPI Number	:	1467629048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUKOLA ODUYELU, DDS, PC

Provider Business Mailing Address
First Line	:	2264 LONDON BRIDGE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-3903
Country	:	US
Telephone Number	:	757-563-2670
Fax Number	:	757-563-2851

Provider Business Practice Location Address
First Line	:	2264 LONDON BRIDGE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-3903
Country	:	US
Telephone Number	:	757-563-2670
Fax Number	:	757-563-2851

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BUKOLA ODUYELU
Credential	:	DDS
Telephone Number	:	757-563-2670

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	06/06/2011

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