Provider Demographics
NPI:1225187511
Name:OLIVER, GARRY LEE (DMD)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:LEE
Last Name:OLIVER
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 1:437 S KY 706
Mailing Address - Street 2:
Mailing Address - City:ISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41149-8966
Mailing Address - Country:US
Mailing Address - Phone:606-738-6904
Mailing Address - Fax:606-738-6904
Practice Address - Street 1:437 S KY 706
Practice Address - Street 2:
Practice Address - City:ISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:41149-8966
Practice Address - Country:US
Practice Address - Phone:606-738-6904
Practice Address - Fax:606-738-6904
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60062122Medicaid