Basic Information
| Provider Information | |||||||||
| NPI: | 1316367352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FATOGUN | ||||||||
| FirstName: | OLUWATOYIN | ||||||||
| MiddleName: | MORENIKE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 1002221E | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 6725 ANNAPOLIS RD | ||||||||
| Address2: | |||||||||
| City: | LANDOVER HILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207841904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017734746 | ||||||||
| FaxNumber: | 3017734941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2014 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 15763 | MD | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 070533400 | 05 | DC | MEDICAID | 110636800 | 05 | MD | MEDICAID |