Provider Demographics
NPI:1740267558
Name:OAK VALLEY MEDICAL & DENTAL, PC
Entity type:Organization
Organization Name:OAK VALLEY MEDICAL & DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VERONA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-329-8573
Mailing Address - Street 1:103 NEW MEADOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15437-1391
Mailing Address - Country:US
Mailing Address - Phone:724-329-8573
Mailing Address - Fax:724-329-1230
Practice Address - Street 1:103 NEW MEADOW RUN DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:PA
Practice Address - Zip Code:15437-1391
Practice Address - Country:US
Practice Address - Phone:724-329-8689
Practice Address - Fax:724-329-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA024882OtherCLIA STATE
39D0925139OtherCLIA FEDERAL
PA102283015-0002Medicaid