Provider Demographics
NPI:1720204845
Name:POULSON, OWEN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:WILLIAM
Last Name:POULSON
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 1:204 TUTTLE CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502
Mailing Address - Country:US
Mailing Address - Phone:785-560-6078
Mailing Address - Fax:785-371-0133
Practice Address - Street 1:711 ZION STREET
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959
Practice Address - Country:US
Practice Address - Phone:530-265-2280
Practice Address - Fax:530-265-5305
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA457571223G0001X
KS608661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice