Provider Demographics
NPI:1215184346
Name:BRENT OLSON, DDS, PLLC
Entity Type:Organization
Organization Name:BRENT OLSON, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-625-7550
Mailing Address - Street 1:730 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6100
Mailing Address - Country:US
Mailing Address - Phone:507-625-7550
Mailing Address - Fax:507-388-3353
Practice Address - Street 1:730 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6100
Practice Address - Country:US
Practice Address - Phone:507-625-7550
Practice Address - Fax:507-388-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty