Provider Demographics
NPI:1598753212
Name:OLSSON, ALEXIS B (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:B
Last Name:OLSSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 E HURON ST
Mailing Address - Street 2:12-100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-926-6333
Mailing Address - Fax:312-926-3444
Practice Address - Street 1:201 E HURON ST
Practice Address - Street 2:12-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-926-6333
Practice Address - Fax:312-926-3444
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U34928Medicare UPIN
986840Medicare ID - Type Unspecified