Provider Demographics
NPI:1588099279
Name:OLIVER, GREGORY KEITH (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:KEITH
Last Name:OLIVER
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 1:2945 N 108TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3709
Mailing Address - Country:US
Mailing Address - Phone:402-827-3434
Mailing Address - Fax:
Practice Address - Street 1:2945 N 108TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3709
Practice Address - Country:US
Practice Address - Phone:402-827-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6186122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1619047784Medicaid