Provider Demographics
NPI:1548416365
Name:OLSON, SHANNON R (DDS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:OLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:
Practice Address - Street 1:150 TEJAS PL
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9123
Practice Address - Country:US
Practice Address - Phone:805-929-3254
Practice Address - Fax:805-931-2569
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57163122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist