Provider Demographics
NPI:1578638250
Name:OLSON, GLEN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:S
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 1:210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-1330
Mailing Address - Country:US
Mailing Address - Phone:435-462-2070
Mailing Address - Fax:435-462-5004
Practice Address - Street 1:210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-1330
Practice Address - Country:US
Practice Address - Phone:435-462-2070
Practice Address - Fax:435-462-5004
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT478628499231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice