Provider Demographics
NPI:1174837983
Name:OLSON, EVAN G (DDS)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:G
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 1:101 WESTVIEW PARK PL
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1401
Mailing Address - Country:US
Mailing Address - Phone:406-393-8877
Mailing Address - Fax:406-752-1124
Practice Address - Street 1:101 WESTVIEW PARK PL
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1401
Practice Address - Country:US
Practice Address - Phone:406-393-8877
Practice Address - Fax:406-752-1124
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9473122300000X
MTD-60371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500625075Medicaid