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General NPI Number Information
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NPI Number | 1801058862
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Entity Type | Organization
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Legal Business Name | MARK S. OLIVERSON, D.M.D.
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Dates
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Enumeration Date | 06/30/2008
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Last Update Date | 10/09/2014
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Provider Practice Location Address
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Address Line | 207 MARGARET ST
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City | SALMON
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State | ID
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Zip | 83467-4400
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Country | US
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Telephone | 208-756-2262
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Fax | 208-756-4473
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Provider Business Mailing Address
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Address Line | 207 MARGARET ST
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City | SALMON
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State | ID
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Zip | 83467-4400
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Country | US
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Telephone | 208-756-2262
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Fax | 208-756-4473
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. MARK S. OLIVERSON
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Credential | D.M.D.
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Telephone | 208-756-2262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D-4013
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License Number State | ID
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