Provider Demographics
NPI:1609855774
Name:OLSON, DAVID GRANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GRANT
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 1:29042 SAN CLEMENTE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-1848
Mailing Address - Country:US
Mailing Address - Phone:706-513-2563
Mailing Address - Fax:
Practice Address - Street 1:2940 STANLEY RD STE 2375
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-2740
Practice Address - Country:US
Practice Address - Phone:210-295-4156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4940888-9922122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist