Provider Demographics
NPI:1689457848
Name:ADEBIYI, DOTUN EBENEZER
Entity type:Individual
Prefix:
First Name:DOTUN
Middle Name:EBENEZER
Last Name:ADEBIYI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 ADMIRAL CALLAGHAN LN
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-3680
Mailing Address - Country:US
Mailing Address - Phone:707-674-5437
Mailing Address - Fax:
Practice Address - Street 1:914 ADMIRAL CALLAGHAN LN
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-3680
Practice Address - Country:US
Practice Address - Phone:707-674-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA110813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program