Provider Demographics
NPI:1184659435
Name:OLSON, GREGORY ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
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 1:5509 EDEN PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5839
Mailing Address - Country:US
Mailing Address - Phone:952-938-6038
Mailing Address - Fax:952-935-9175
Practice Address - Street 1:5509 EDEN PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5839
Practice Address - Country:US
Practice Address - Phone:952-938-6038
Practice Address - Fax:952-935-9175
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN674718300OtherSTATE MEDICAL ASSISTANCE#