Provider Demographics
NPI:1407927304
Name:HUNTER CROOM, OLIVIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:
Last Name:HUNTER CROOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:
Practice Address - Street 1:1520 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-2855
Practice Address - Country:US
Practice Address - Phone:419-255-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4657336Medicaid