Provider Demographics
NPI:1497313530
Name:OLIVE DENTAL GROUP PC
Entity Type:Organization
Organization Name:OLIVE DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:MATHAI
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-987-2237
Mailing Address - Street 1:10300 KATY FWY APT 141
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-5125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4407 FM 1960 RD W STE D
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77068-3461
Practice Address - Country:US
Practice Address - Phone:267-987-2237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty