Provider Demographics
NPI:1083765697
Name:OLSON, RICHARD A (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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 1:1211 STANLEY AVENUE
Mailing Address - Street 2:TOMHAVE OLSON DENTAL ASSOC
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-879-4541
Mailing Address - Fax:218-879-4542
Practice Address - Street 1:1211 STANLEY AVENUE
Practice Address - Street 2:TOMHAVE OLSON DENTAL ASSOC
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-4541
Practice Address - Fax:218-879-4542
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9213122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist