Provider Demographics
NPI:1518389733
Name:OLESON, BRIAN RAY (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:RAY
Last Name:OLESON
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:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:HOODSPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98548-0817
Mailing Address - Country:US
Mailing Address - Phone:360-877-5151
Mailing Address - Fax:360-877-5134
Practice Address - Street 1:N. 68 CUSHMAN AVE.
Practice Address - Street 2:
Practice Address - City:HOODSPORT
Practice Address - State:WA
Practice Address - Zip Code:98548-0817
Practice Address - Country:US
Practice Address - Phone:360-877-5151
Practice Address - Fax:360-877-5134
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5463122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist