Basic Information
| Provider Information | |||||||||
| NPI: | 1376983908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLAOSO | ||||||||
| FirstName: | ISMAIL | ||||||||
| MiddleName: | ADEYEMI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S., M.P.H | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 343 MAIN ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135285565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 343 MAIN ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135285565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DL12333 | MA | Y | Dental Providers | Dentist | 122300000X | 0401414551 | VA | N | Dental Providers | Dentist | 1223D0001X | 0401414551 | VA | N | Dental Providers | Dentist | Dental Public Health |
No ID Information.