MEDICARE: DR. WILLIE TRANARD OLIVER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN014758	GA

General Provider Information

NPI Number	:	1962842195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIE TRANARD OLIVER DDS

Provider Business Mailing Address
First Line	:	555 COALVILLE DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-9364
Country	:	US
Telephone Number	:	615-596-1015
Fax Number	:

Provider Business Practice Location Address
First Line	:	52 EXECUTIVE PARK S
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2217
Country	:	US
Telephone Number	:	614-292-2401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2013
Last Update Date	:	12/04/2015

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