MEDICARE: CLEONA OLIVER

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	32279	TX
2	1223G0001X	General Practice Dentistry	32279	TX

General Provider Information

NPI Number	:	1881053221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLEONA OLIVER

Provider Business Mailing Address
First Line	:	18015 SUMMER KNOLL DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3401
Country	:	US
Telephone Number	:	210-497-7151
Fax Number	:

Provider Business Practice Location Address
First Line	:	11901 SHADOW CREEK PKWY STE 135
Second Line	:
City	:	PEARLAND
State	:	TX
Zip	:	77584-7346
Country	:	US
Telephone Number	:	210-497-7151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2016
Last Update Date	:	04/02/2018

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Directions to “ CLEONA OLIVER ” Practice Location

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