Provider Demographics
NPI:1629700091
Name:OLIVERSON, ELIJAH DON (DDS)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:DON
Last Name:OLIVERSON
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 1:1093 HANCOCK RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5904
Mailing Address - Country:US
Mailing Address - Phone:928-758-5588
Mailing Address - Fax:
Practice Address - Street 1:1093 HANCOCK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5904
Practice Address - Country:US
Practice Address - Phone:928-758-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-25
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0114771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice