Basic Information
| Provider Information | |||||||||
| NPI: | 1003136904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLLOCK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 W WELLSBORO ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169331411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706621945 | ||||||||
| FaxNumber: | 5706622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 SEYMOUR ST | ||||||||
| Address2: | |||||||||
| City: | BLOSSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169121418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706383468 | ||||||||
| FaxNumber: | 5706383637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS038254 | PA | Y | Dental Providers | Dentist |
No ID Information.