Provider Demographics
NPI:1851442073
Name:OLIVER, JOHN MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:OLIVER
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 1:2621 NEW WALKERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-1948
Mailing Address - Country:US
Mailing Address - Phone:336-724-5054
Mailing Address - Fax:336-724-5033
Practice Address - Street 1:2621 NEW WALKERTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-1948
Practice Address - Country:US
Practice Address - Phone:336-724-5054
Practice Address - Fax:336-724-5033
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC90168OtherBLUE CROSS BLUE SHIELD
NC8990168Medicaid
NC8990168Medicaid