Provider Demographics
NPI:1124437553
Name:TAKLA, OLYSIA N (DMD)
Entity type:Individual
Prefix:DR
First Name:OLYSIA
Middle Name:N
Last Name:TAKLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5813 W DEL LAGO CIR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6205
Mailing Address - Country:US
Mailing Address - Phone:440-822-4038
Mailing Address - Fax:
Practice Address - Street 1:5855 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-806-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0091801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice