Healthcare Provider Details

I. General information

NPI: 1982692919
Provider Name (Legal Business Name): JACQUELYN MARIE OLGEATY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR 88 MDG/SGDD
WRIGHT PATTERSON AFB OH
45433-5546
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR BLDG 830
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9613
  • Fax:
Mailing address:
  • Phone: 937-257-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020006280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: