Provider Demographics
NPI: | 1508426818 |
---|---|
Name: | BETHANY J. OLSON DDS, LLC |
Entity Type: | Organization |
Organization Name: | BETHANY J. OLSON DDS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DENTIST/OWNDER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | BETHANY |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | OLSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 402-721-2252 |
Mailing Address - Street 1: | 2220 N NYE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | FREMONT |
Mailing Address - State: | NE |
Mailing Address - Zip Code: | 68025-2543 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 402-721-2252 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2220 N NYE AVE |
Practice Address - Street 2: | |
Practice Address - City: | FREMONT |
Practice Address - State: | NE |
Practice Address - Zip Code: | 68025-2543 |
Practice Address - Country: | US |
Practice Address - Phone: | 402-721-2252 |
Practice Address - Fax: | 402-721-4826 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-06-18 |
Last Update Date: | 2019-06-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NE | 10025535600 | Medicaid |