Provider Demographics
NPI:1902012776
Name:OLIVER, KEVIN JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:OLIVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:JOSEPH
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:7720 JONES MALTSBERGER RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6946
Mailing Address - Country:US
Mailing Address - Phone:210-804-2212
Mailing Address - Fax:
Practice Address - Street 1:7720 JONES MALTSBERGER RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6946
Practice Address - Country:US
Practice Address - Phone:210-804-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742657575OtherTAX ID
TX1208605-03Medicaid