Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DS038254 | PA |
NPI | 1003136904 |
---|---|
Provider Name | Stephen Joseph Ollock |
First Address | Mansfield, PA 16933-1125 |
Second Address | Blossburg, PA 16912-1418 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2010 |
Last Update Date | 23/12/2010 |