Healthcare Provider Details

I. General information

NPI: 1629174354
Provider Name (Legal Business Name): PETER M OLLMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 E MAIN ST STE #2
MEDFORD OR
97504-7115
US

IV. Provider business mailing address

846 BLACKBERRY LN
ASHLAND OR
97520-1459
US

V. Phone/Fax

Practice location:
  • Phone: 541-858-0740
  • Fax: 541-776-5342
Mailing address:
  • Phone: 541-708-0347
  • Fax: 802-748-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9378
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: