Provider Demographics
NPI:1306933635
Name:J MARK OLIVER DDS PA
Entity type:Organization
Organization Name:J MARK OLIVER DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-724-5054
Mailing Address - Street 1:2621 NEW WALKERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101
Mailing Address - Country:US
Mailing Address - Phone:336-724-5054
Mailing Address - Fax:336-724-5033
Practice Address - Street 1:2621 NEW WALKERTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101
Practice Address - Country:US
Practice Address - Phone:336-724-5054
Practice Address - Fax:336-724-5033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990168Medicaid
NC8990168Medicaid