Provider Demographics
NPI:1578632139
Name:OLSON, RANDALL CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:CLARK
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 1:610 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2213
Mailing Address - Country:US
Mailing Address - Phone:206-241-2091
Mailing Address - Fax:206-241-1908
Practice Address - Street 1:610 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2213
Practice Address - Country:US
Practice Address - Phone:206-241-2091
Practice Address - Fax:206-241-1908
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA59071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice