Organization Name: | MARK S. OLIVERSON, D.M.D. |
NPI Number: | 1801058862 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MARK S. OLIVERSON (GENERAL DENTIST) |
Mailing Address: | 207 Margaret St Salmon |
State: | ID US |
Postal Code: | 834674400 |
Phone Number: | 2087562262 |
Fax Number: | 2087564473 |
NPI Enumeration Date: | 06/30/2008 |
NPI Last Update Date: | 10/09/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | D-4013 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |