Provider Demographics
NPI:1619030368
Name:OLSEN, LONNIE EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:EUGENE
Last Name:OLSEN
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 1:3612 GALLEY RD STE D
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4355
Mailing Address - Country:US
Mailing Address - Phone:719-596-7716
Mailing Address - Fax:719-596-0906
Practice Address - Street 1:3612 GALLEY RD STE D
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4355
Practice Address - Country:US
Practice Address - Phone:719-596-7716
Practice Address - Fax:719-596-0906
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD-1-04027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist