Provider Demographics
NPI:1336302249
Name:OLSEN, JUSTIN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:T
Last Name:OLSEN
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 1:1201 N. STONEWALL AVE
Mailing Address - Street 2:PO BOX 26901
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73190-3044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N. STONEWALL AVE
Practice Address - Street 2:POST OFFICE BOX 26901
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73190-3044
Practice Address - Country:US
Practice Address - Phone:404-271-4148
Practice Address - Fax:405-271-6012
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics