Provider Demographics
NPI:1689797458
Name:OLIVERSON, MARK S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:OLIVERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4400
Mailing Address - Country:US
Mailing Address - Phone:208-756-2262
Mailing Address - Fax:208-756-4473
Practice Address - Street 1:207 MARGARET ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4400
Practice Address - Country:US
Practice Address - Phone:208-756-2262
Practice Address - Fax:208-756-4473
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807527500Medicaid