Provider Demographics
NPI:1366461758
Name:OLSEN, JAMES RAYMOND (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RAYMOND
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 S 1300 E STE L3
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3674
Mailing Address - Country:US
Mailing Address - Phone:801-486-5177
Mailing Address - Fax:
Practice Address - Street 1:1955 S 1300 E STE L3
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3674
Practice Address - Country:US
Practice Address - Phone:801-486-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT131429-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice