Healthcare Provider Details

I. General information

NPI: 1457695413
Provider Name (Legal Business Name): OLIVER STREET 5.01(A) INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 HARVEST HILL RD STE 290
DALLAS TX
75230-5826
US

IV. Provider business mailing address

5310 HARVEST HILL RD STE 290
DALLAS TX
75230-5826
US

V. Phone/Fax

Practice location:
  • Phone: 214-420-0672
  • Fax: 214-736-0512
Mailing address:
  • Phone: 214-420-0672
  • Fax: 214-736-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL SINGH
Title or Position: CEO
Credential:
Phone: 214-420-0651