Provider Demographics
NPI:1043347834
Name:LILLIS-OLSON, JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:LILLIS-OLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 WILLAMETTE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2843
Mailing Address - Country:US
Mailing Address - Phone:541-687-2717
Mailing Address - Fax:
Practice Address - Street 1:2015 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-2843
Practice Address - Country:US
Practice Address - Phone:541-687-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD61911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice