Basic Information
| Provider Information | |||||||||
| NPI: | 1700267523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AKINWANDE | ||||||||
| FirstName: | KOLADE | ||||||||
| MiddleName: | ADEOLA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADEROJU | ||||||||
| OtherFirstName: | KOLADE | ||||||||
| OtherMiddleName: | ADEOLA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.D.S | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 N NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7195761929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 BRENTWOOD RD NE STE B-1 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200181052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022694746 | ||||||||
| FaxNumber: | 2022696994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2015 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401415114 | VA | N | Dental Providers | Dentist | 122300000X | 15992 | MD | N | Dental Providers | Dentist | 122300000X | DEN1001663 | DC | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1700267523 | 05 | MD | MEDICAID | PENDING | 05 | DC | MEDICAID |