MEDICARE: OAK VALLEY MEDICAL & DENTAL, 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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	024882	OTHER	PA	CLIA STATE
2	39D0925139	OTHER		CLIA FEDERAL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740267558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAK VALLEY MEDICAL & DENTAL, PC

Provider Business Mailing Address
First Line	:	103 NEW MEADOW RUN DR
Second Line	:
City	:	FARMINGTON
State	:	PA
Zip	:	15437-1391
Country	:	US
Telephone Number	:	724-329-8573
Fax Number	:	724-329-1230

Provider Business Practice Location Address
First Line	:	103 NEW MEADOW RUN DR
Second Line	:
City	:	FARMINGTON
State	:	PA
Zip	:	15437-1391
Country	:	US
Telephone Number	:	724-329-8689
Fax Number	:	724-329-1230

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VERONA M BOLLER
Credential	:	MD
Telephone Number	:	724-329-8573

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	10/07/2019

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