Provider Demographics
NPI:1881053221
Name:OLIVER, CLEONA
Entity type:Individual
Prefix:
First Name:CLEONA
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18015 SUMMER KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3401
Mailing Address - Country:US
Mailing Address - Phone:210-497-7151
Mailing Address - Fax:
Practice Address - Street 1:11901 SHADOW CREEK PKWY STE 135
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7346
Practice Address - Country:US
Practice Address - Phone:210-497-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-13
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32279122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist