MEDICARE: FUNMI ABOSEDE

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

General Provider Information

NPI Number	:	1902449325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNMI ABOSEDE

Provider Business Mailing Address
First Line	:	3809 S CONGRESS AVE APT 447
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-8035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	424 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-3018
Country	:	US
Telephone Number	:	361-552-2977
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FUNMI ABOSEDE
Credential	:	DMD
Telephone Number	:	312-498-9323

Provider Enumeration Date	:	10/18/2019
Last Update Date	:	11/14/2019

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Directions to “FUNMI ABOSEDE ” Practice Location

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