Basic Information
| Provider Information | |||||||||
| NPI: | 1558699744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADONAI DENTAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 LOOP 20 | ||||||||
| Address2: | #A6 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780435009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567278200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3210 LOOP 20 | ||||||||
| Address2: | #A6 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780435009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567278200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2009 | ||||||||
| LastUpdateDate: | 12/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | OLAKUNLE | ||||||||
| AuthorizedOfficialMiddleName: | IBITOYE | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 4049185942 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 24029 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1467616268 | 05 | TX | MEDICAID |