Provider Demographics
NPI:1619371689
Name:OLYMPIA HILLS FAMILY DENTAL, PC
Entity Type:Organization
Organization Name:OLYMPIA HILLS FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERAME
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAFEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-845-8831
Mailing Address - Street 1:8056 SHIN OAK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233
Mailing Address - Country:US
Mailing Address - Phone:210-658-3131
Mailing Address - Fax:210-658-9033
Practice Address - Street 1:8056 SHIN OAK DR
Practice Address - Street 2:STE 100
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233
Practice Address - Country:US
Practice Address - Phone:210-658-3131
Practice Address - Fax:210-658-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty