Provider Demographics
NPI:1629140207
Name:OLIVER, MARK DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:OLIVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W BROOME ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3107
Mailing Address - Country:US
Mailing Address - Phone:706-884-8523
Mailing Address - Fax:706-884-4679
Practice Address - Street 1:409 W BROOME ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3107
Practice Address - Country:US
Practice Address - Phone:706-884-8523
Practice Address - Fax:706-884-4679
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist