Provider Demographics
NPI:1033223805
Name:OLSON, JOHN BRADLEY (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRADLEY
Last Name:OLSON
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 1:217 S THIRD ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3778
Mailing Address - Country:US
Mailing Address - Phone:815-758-2800
Mailing Address - Fax:815-787-2801
Practice Address - Street 1:217 S THIRD ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3778
Practice Address - Country:US
Practice Address - Phone:815-758-2800
Practice Address - Fax:815-787-2801
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist