Provider Demographics
NPI:1609005966
Name:OLSON, KELBY JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELBY
Middle Name:JAMES
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 1:794 EASTLAND DR
Mailing Address - Street 2:#2
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-5036
Practice Address - Street 1:1361 E 16TH ST
Practice Address - Street 2:#2
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2008
Practice Address - Country:US
Practice Address - Phone:208-677-5198
Practice Address - Fax:208-678-2245
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-42181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice