Provider Demographics
NPI:1902444169
Name:OLIVE DENTAL OKC PLLC
Entity Type:Organization
Organization Name:OLIVE DENTAL OKC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-612-8577
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:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1891286092Medicaid