Oluwole Olubunmi Fadahunsi, DMD

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

0401416435 Issued in VA

Practice address

7611 Little River Tpke Ste 101E
Annandale, VA 22003-2630

Phone

(703) 634-4195

NPI assigned

May 11, 2015

Last updated

Sep 15, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 5

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Mar 2, 2023 through Mar 2, 2027

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Sigma Dental LLC

  dba Krupp Center, Maxillofacial, Oral & Cosmetic Surgery

  • Oral and Maxillofacial Surgery (Dentist)
  • Towson, MD
  • NPI 1093437121
  NPD Authorized official
• Alex Sharifian D.D.S., Creve Coeur Dentistry, P.C.

  dba Creve Coeur Dentistry

  • Dentist
  • Creve Coeur, MO
  • NPI 1821487596
  NPD (past)
• Dr Bernard Krupp, DDS, Oms, PA

  • Oral & Maxillofacial Surgery (D.M.D.)
  • Towson, MD
  • NPI 1023001641
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1431302400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663200000000",
    "number": "1396123352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7611 LITTLE RIVER TPKE STE 101E",
            "city": "ANNANDALE",
            "state": "VA",
            "postal_code": "220032630",
            "telephone_number": "703-634-4195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7611 LITTLE RIVER TPKE STE 101E",
            "city": "ANNANDALE",
            "state": "VA",
            "postal_code": "220032630",
            "telephone_number": "703-634-4195"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1220 E Joppa Rd Ste 314",
            "address_purpose": "LOCATION",
            "city": "Towson",
            "state": "MD",
            "postal_code": "212865811",
            "country_code": "US",
            "telephone_number": "410-583-7600",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "11437 Olive Blvd",
            "address_purpose": "LOCATION",
            "city": "Creve Coeur",
            "state": "MO",
            "postal_code": "631417108",
            "country_code": "US",
            "telephone_number": "314-355-2000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FADAHUNSI",
        "first_name": "OLUWOLE",
        "middle_name": "OLUBUNMI",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-05-11",
        "last_updated": "2022-09-15",
        "certification_date": "2021-12-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MD",
            "license": "16193",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "DC",
            "license": "DEN1001975",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MO",
            "license": "2019016472",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "IL",
            "license": "19032524",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0401416435",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://epicproxy.et0965.epichosted.com/FHIRProxy/api/FHIR/DSTU2/",
            "affiliation": "Y",
            "endpointDescription": "MBMC EPIC",
            "affiliationName": "Missouri Baptist Medical Center",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "3015 N Ballas Rd",
            "city": "Saint Louis",
            "state": "MO",
            "country_code": "US",
            "postal_code": "631312329",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Evergreen Health Care Management LLC
• Evergreen OB/GYN P.C.
• Evergreen Pharmacy, Inc (Annandale Pharmacy)
• Exeeda Wellness LLC
• Ez Health, Inc.
• Fair Ridge Orthopedics, Inc
• Fairfax Psychiatry LLC
• Fairfax Child and Family Therapy LLC
• Fairfax Heart Associates
• Fairfax Orthopaedics, PLLC

• Oral and Maxillofacial Surgery (Dentist) in Annandale, VA
• Providers in Annandale, VA by specialty
• Oral and Maxillofacial Surgery (Dentist) in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.