Healthcare Provider Details

I. General information

NPI: 1477517498
Provider Name (Legal Business Name): HEATHER RUTH OLMO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-295-2368
  • Fax:
Mailing address:
  • Phone: 210-295-2368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number0401412076
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: