Provider Demographics
NPI:1780804187
Name:GENIS, OLEG (DMD)
Entity type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:GENIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8541 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-1215
Mailing Address - Country:US
Mailing Address - Phone:215-742-7750
Mailing Address - Fax:215-742-0954
Practice Address - Street 1:8541 BUSTLETON AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-1215
Practice Address - Country:US
Practice Address - Phone:215-742-7750
Practice Address - Fax:215-742-0954
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029657L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice