Provider Demographics
NPI:1548009640
Name:OLIVA, SOFIA VICTORIA
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:VICTORIA
Last Name:OLIVA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 CHARLESGATE E APT 74
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3639
Mailing Address - Country:US
Mailing Address - Phone:305-310-9254
Mailing Address - Fax:
Practice Address - Street 1:100 UNIVERSAL CITY PLZ
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91608-1002
Practice Address - Country:US
Practice Address - Phone:305-310-9254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X390200000X
MADN100003541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program