Provider Demographics
NPI:1225769227
Name:OLSEN, BRADLEY (CDT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:OLSEN
Suffix:
Gender:M
Credentials:CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S STATE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:507-235-5985
Mailing Address - Fax:
Practice Address - Street 1:717 S STATE ST STE 2
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-235-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT150125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist