Provider Demographics
NPI:1770250821
Name:DUBRAY, OLIVIA ROSE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:DUBRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 HAT BENDER LOOP
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2045
Mailing Address - Country:US
Mailing Address - Phone:269-532-0100
Mailing Address - Fax:
Practice Address - Street 1:11828 RING DR STE 102
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-2106
Practice Address - Country:US
Practice Address - Phone:512-640-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX377841223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice