Provider Demographics
NPI:1598399602
Name:OLSON, ALEX JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JOHN
Last Name:OLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 S PICHER AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2602 S PICHER AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1641
Practice Address - Country:US
Practice Address - Phone:417-781-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172407122300000X
KS618331223P0221X
MO20220083201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist