Provider Demographics
NPI:1639693336
Name:OLIVARES, ROBERTO MIGUEL (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:MIGUEL
Last Name:OLIVARES
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 1:7458 LOUIS PASTEUR DR APT 1605
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4520
Mailing Address - Country:US
Mailing Address - Phone:956-340-9292
Mailing Address - Fax:
Practice Address - Street 1:5250 BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7017
Practice Address - Country:US
Practice Address - Phone:210-349-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist