Healthcare Provider Details

I. General information

NPI: 1619307485
Provider Name (Legal Business Name): JOEL OLMOS JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10668 RIVERSIDE DR
TOLUCA LAKE CA
91602-2319
US

IV. Provider business mailing address

18635 SOLEDAD CANYON RD STE 108
CANYON COUNTRY CA
91351-3723
US

V. Phone/Fax

Practice location:
  • Phone: 818-760-9912
  • Fax: 818-760-9913
Mailing address:
  • Phone: 661-299-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: