Provider Demographics
NPI:1043757677
Name:TOLLIVER, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 SIGHTSEEING RD, BLDG 2828
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7770 SIGHTSEEING RD, BLDG 2828
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-545-3956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11317124Q00000X
AL7795124Q00000X
TN5689124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist