Provider Demographics
NPI:1679244883
Name:OLSON DENTAL CORPORATION
Entity Type:Organization
Organization Name:OLSON DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-533-5775
Mailing Address - Street 1:14 RUE DU PARC
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-3424
Mailing Address - Country:US
Mailing Address - Phone:702-533-5775
Mailing Address - Fax:
Practice Address - Street 1:7677 CENTER AVE STE 305
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-9119
Practice Address - Country:US
Practice Address - Phone:714-847-8501
Practice Address - Fax:714-908-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA63843OtherCALIFORNIA DENTAL LICENSE
FO3580114OtherDEA REGISTRATION NUMBER