=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336211317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TED OLEY OELLERICH DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2357 HWY 88
-----------------------------------------------------
City | HEPHZIBAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-592-9551
-----------------------------------------------------
Fax | 706-592-9556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 263 2357 GEORGIA HIGHWAY 88
-----------------------------------------------------
City | HEPHZIBAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-592-9551
-----------------------------------------------------
Fax | 706-592-9556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 010818
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------