Basic Information
Provider Information | |||||||||
NPI: | 1144557281 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BELLO | ||||||||
FirstName: | ADESUWA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OSUNDE | ||||||||
OtherFirstName: | ADESUWA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1601 PRECISION PARK LN | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921731345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196624100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3177 OCEAN VIEW BLVD | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921131432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196624100 | ||||||||
FaxNumber: | 6192325922 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2009 | ||||||||
LastUpdateDate: | 05/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 58654 | CA | N |   | Dental Providers | Dentist |   | 122300000X | 057126 | NY | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 04507282 | 05 | NY |   | MEDICAID | 057126 | 01 | NY | LICENSE | OTHER |