MEDICARE: DR. OLAKUNBI IBIRONKE ONIME DDS

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	1223G0001X	General Practice Dentistry	24463	TX

General Provider Information

NPI Number	:	1477535821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLAKUNBI IBIRONKE ONIME DDS

Provider Business Mailing Address
First Line	:	6559 OLD JACKSONVILLE HWY
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-0720
Country	:	US
Telephone Number	:	903-747-3839
Fax Number	:	903-747-3842

Provider Business Practice Location Address
First Line	:	6559 OLD JACKSONVILLE HWY
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-0720
Country	:	US
Telephone Number	:	903-747-3839
Fax Number	:	903-747-3842

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	05/24/2021

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