Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 0401414551 | VA |
Y | 122300000X | Dentist | DL12333 | MA |
N | 1223D0001X | Dental Public Health | 0401414551 | VA |
NPI | 1376983908 |
---|---|
Provider Name | Dr. Ismail Adeyemi Jolaoso |
First Address | Great Barrington, MA 01230-1846 |
Second Address | Great Barrington, MA 01230-1846 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2013 |
Last Update Date | 02/06/2015 |