Provider Demographics
NPI:1043390404
Name:GREGORY W. OLSON, DDS PLLC
Entity Type:Organization
Organization Name:GREGORY W. OLSON, DDS PLLC
Other - Org Name:HARTMAN & OLSON PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-675-7573
Mailing Address - Street 1:31775 STATE ROUTE 20 STE A1
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5104
Mailing Address - Country:US
Mailing Address - Phone:360-675-7573
Mailing Address - Fax:
Practice Address - Street 1:31775 STATE ROUTE 20 STE A1
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5104
Practice Address - Country:US
Practice Address - Phone:360-675-7573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA81351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036041Medicaid
WA469447OtherUNITED CONCORDIA ID#