Provider Demographics
NPI:1619047784
Name:DR GREGORY K OLIVER PC
Entity Type:Organization
Organization Name:DR GREGORY K OLIVER PC
Other - Org Name:ALPHA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRONT OFFICE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:R
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-827-3434
Mailing Address - Street 1:2945 N 108TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164
Mailing Address - Country:US
Mailing Address - Phone:402-827-3434
Mailing Address - Fax:402-827-3436
Practice Address - Street 1:2945 N 108TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164
Practice Address - Country:US
Practice Address - Phone:402-827-3434
Practice Address - Fax:402-827-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6186122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
05738OtherBLUE CROSS BLUE SHIELD
NE1619047784Medicaid
05738OtherBLUE CROSS BLUE SHIELD