Provider Demographics
NPI:1801058862
Name:MARK S. OLIVERSON, D.M.D.
Entity type:Organization
Organization Name:MARK S. OLIVERSON, D.M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:OLIVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-756-2262
Mailing Address - Street 1:207 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4400
Mailing Address - Country:US
Mailing Address - Phone:208-756-2262
Mailing Address - Fax:208-756-4473
Practice Address - Street 1:207 MARGARET ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4400
Practice Address - Country:US
Practice Address - Phone:208-756-2262
Practice Address - Fax:208-756-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4013261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807527500Medicaid
ID9202414OtherIDAHO SMILES