Provider Demographics
NPI:1659062750
Name:OLSEN, MATTHEW JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
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 1:1997 S 3475 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-4900
Mailing Address - Country:US
Mailing Address - Phone:512-645-5220
Mailing Address - Fax:
Practice Address - Street 1:1480 S ORCHARD DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5142
Practice Address - Country:US
Practice Address - Phone:801-295-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13380931-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice