Provider Demographics
NPI:1437591401
Name:OLIVER, TRISSTAR (DDS)
Entity Type:Individual
Prefix:
First Name:TRISSTAR
Middle Name:
Last Name:OLIVER
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 1:2292 DALTON DR STE F
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8961
Mailing Address - Country:US
Mailing Address - Phone:931-503-1111
Mailing Address - Fax:
Practice Address - Street 1:782 WEATHERLY DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8941
Practice Address - Country:US
Practice Address - Phone:931-503-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0442000179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0442000179OtherCOMMONWEALTH OF VIRGINIA BOARD OF DENTISTRY (TEMPORARY RESIDENT DENTAL LICENSE)