Healthcare Provider Details

I. General information

NPI: 1083985345
Provider Name (Legal Business Name): OLVERA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N KINGSHIGHWAY BLVD
SAINT LOUIS MO
63113-1408
US

IV. Provider business mailing address

1301 N KINGSHIGHWAY BLVD
SAINT LOUIS MO
63113-1408
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-1434
  • Fax: 314-367-2217
Mailing address:
  • Phone: 314-367-1434
  • Fax: 314-367-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2009024563
License Number StateMO

VIII. Authorized Official

Name: DR. MELISSA SELENE OLVERA
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 314-367-1434