Provider Demographics
NPI:1003136904
Name:OLLOCK, STEPHEN JOSEPH (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:OLLOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W WELLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1411
Mailing Address - Country:US
Mailing Address - Phone:570-662-1945
Mailing Address - Fax:570-662-2390
Practice Address - Street 1:116 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:BLOSSBURG
Practice Address - State:PA
Practice Address - Zip Code:16912-1418
Practice Address - Country:US
Practice Address - Phone:570-638-3468
Practice Address - Fax:570-638-3637
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist