Provider Demographics
NPI:1194226332
Name:OLIVA, OCTAVIO MARIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:MARIO
Last Name:OLIVA
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 1:317 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GOLIAD
Mailing Address - State:TX
Mailing Address - Zip Code:77963-4167
Mailing Address - Country:US
Mailing Address - Phone:205-527-7037
Mailing Address - Fax:
Practice Address - Street 1:317 S MARKET ST
Practice Address - Street 2:
Practice Address - City:GOLIAD
Practice Address - State:TX
Practice Address - Zip Code:77963-4167
Practice Address - Country:US
Practice Address - Phone:361-645-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice