Provider Demographics
NPI:1053300392
Name:OLSON, GARY R (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
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 1:1319 W WESTGATE TER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3304
Mailing Address - Country:US
Mailing Address - Phone:773-488-5300
Mailing Address - Fax:
Practice Address - Street 1:6907 S WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3734
Practice Address - Country:US
Practice Address - Phone:773-488-5300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist