Provider Demographics
NPI:1265784706
Name:JOSIE G OLIVA DDS PC
Entity type:Organization
Organization Name:JOSIE G OLIVA DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:GEMARIE
Authorized Official - Last Name:OLIVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:224-610-9823
Mailing Address - Street 1:9058 N CUMBERLAND AVE
Mailing Address - Street 2:APT 2W
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1447
Mailing Address - Country:US
Mailing Address - Phone:224-610-9823
Mailing Address - Fax:
Practice Address - Street 1:3074 W IL ROUTE 60
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-4270
Practice Address - Country:US
Practice Address - Phone:847-970-7070
Practice Address - Fax:847-970-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027925122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty