Provider Demographics
NPI:1609971043
Name:OLSEN, BRADY J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:J
Last Name:OLSEN
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 1:185 S 400 E STE 201
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4861
Mailing Address - Country:US
Mailing Address - Phone:801-298-1101
Mailing Address - Fax:801-298-1101
Practice Address - Street 1:185 S 400 E STE 201
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4861
Practice Address - Country:US
Practice Address - Phone:801-298-1101
Practice Address - Fax:801-298-1101
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7270739-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty