Provider Demographics
NPI:1558357863
Name:OLSON, GARY B (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:B
Last Name:OLSON
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 1:3930 8TH ST S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-6511
Mailing Address - Country:US
Mailing Address - Phone:715-421-3366
Mailing Address - Fax:715-421-3353
Practice Address - Street 1:3930 8TH ST S
Practice Address - Street 2:SUITE 202
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6511
Practice Address - Country:US
Practice Address - Phone:715-421-3366
Practice Address - Fax:715-421-3353
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1723G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI76597Medicare ID - Type Unspecified