Provider Demographics
NPI:1437495074
Name:OLSON, MANDY MARIA (DMD)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIA
Last Name:OLSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 WESTSIDE DR
Mailing Address - Street 2:APT. #307
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1210
Mailing Address - Country:US
Mailing Address - Phone:954-937-6718
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-01
Last Update Date:2013-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8415788-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist