Provider Demographics
NPI:1659591220
Name:OLSEN, RICHARD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
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 1:155 N WESTHAVEN DR
Mailing Address - Street 2:APT 105
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904
Mailing Address - Country:US
Mailing Address - Phone:920-237-0084
Mailing Address - Fax:
Practice Address - Street 1:404 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5547
Practice Address - Country:US
Practice Address - Phone:920-233-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001144-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice