Provider Demographics
NPI:1831605419
Name:OLIVE DENTAL
Entity type:Organization
Organization Name:OLIVE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QIONG
Authorized Official - Middle Name:ZHOU
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-470-2200
Mailing Address - Street 1:5500 NW EXPRESSWAY STE B
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5218
Mailing Address - Country:US
Mailing Address - Phone:405-470-2200
Mailing Address - Fax:405-470-2392
Practice Address - Street 1:5500 NW EXPRESSWAY STE B
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5218
Practice Address - Country:US
Practice Address - Phone:405-470-2200
Practice Address - Fax:405-470-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK6497261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1629400510Medicaid