Provider Demographics
NPI:1104097872
Name:ABOLARIN LLC
Entity type:Organization
Organization Name:ABOLARIN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:O
Authorized Official - Last Name:ABOLARIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-613-5808
Mailing Address - Street 1:7439 FRANKFORD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3600
Mailing Address - Country:US
Mailing Address - Phone:215-613-5808
Mailing Address - Fax:215-613-5818
Practice Address - Street 1:6404 ROOSEVELT BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2943
Practice Address - Country:US
Practice Address - Phone:215-831-1023
Practice Address - Fax:215-831-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0373191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102051413Medicaid
PA9183726OtherDORAL