Healthcare Provider Details

I. General information

NPI: 1295016608
Provider Name (Legal Business Name): MICAH M. OLLER D.M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 E CALAVERAS BLVD SUITE B
MILPITAS CA
95035-5453
US

IV. Provider business mailing address

466 E CALAVERAS BLVD SUITE B
MILPITAS CA
95035-5453
US

V. Phone/Fax

Practice location:
  • Phone: 408-263-6660
  • Fax: 408-263-8409
Mailing address:
  • Phone: 408-263-6660
  • Fax: 408-263-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number45163
License Number StateCA

VIII. Authorized Official

Name: DR. MICAH M. OLLER
Title or Position: OWNER
Credential: D.M.D.
Phone: 408-263-6660