Provider Demographics
NPI:1710093398
Name:NOURI, OLGA R (DMD)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:R
Last Name:NOURI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:OLGA
Other - Middle Name:REVILLA
Other - Last Name:NOURI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:801 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589
Mailing Address - Country:US
Mailing Address - Phone:956-787-8915
Mailing Address - Fax:956-787-2021
Practice Address - Street 1:801 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-2276
Practice Address - Country:US
Practice Address - Phone:956-787-8915
Practice Address - Fax:956-787-2021
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344333502Medicaid
TX541522YLALOtherMEDICARE