Provider Demographics
NPI:1710477658
Name:OLSEN, ANDELYN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDELYN
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 SMILEY RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-1808
Mailing Address - Country:US
Mailing Address - Phone:702-668-7308
Mailing Address - Fax:
Practice Address - Street 1:4370 SMILEY RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-1808
Practice Address - Country:US
Practice Address - Phone:702-668-7308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV65401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6540OtherNEVADA STATE DENTAL BOARD
FO4964854OtherDEA LICENSE
NV6540OtherNEVADA STATE DENTAL BOARD