MEDICARE: JOSIE G OLIVA DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019027925	IL

General Provider Information

NPI Number	:	1265784706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSIE G OLIVA DDS PC

Provider Business Mailing Address
First Line	:	9058 N CUMBERLAND AVE
Second Line	:	APT 2W
City	:	NILES
State	:	IL
Zip	:	60714-1447
Country	:	US
Telephone Number	:	224-610-9823
Fax Number	:

Provider Business Practice Location Address
First Line	:	3074 W IL ROUTE 60
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4270
Country	:	US
Telephone Number	:	847-970-7070
Fax Number	:	847-970-7077

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSIE GEMARIE OLIVA
Credential	:	DDS
Telephone Number	:	224-610-9823

Provider Enumeration Date	:	10/09/2012
Last Update Date	:	10/09/2012

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