Provider Demographics
NPI:1174590699
Name:OLIS, JOHN MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:OLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-2143
Mailing Address - Country:US
Mailing Address - Phone:740-622-6797
Mailing Address - Fax:740-622-6797
Practice Address - Street 1:234 CAMBRIDGE RD
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2143
Practice Address - Country:US
Practice Address - Phone:740-622-6797
Practice Address - Fax:740-622-6797
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2009-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0167781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0510478Medicaid