Provider Demographics
NPI:1740745439
Name:SUSAN OLSON DMD INC
Entity Type:Organization
Organization Name:SUSAN OLSON DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:949-748-0710
Mailing Address - Street 1:PO BOX 872461
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-2461
Mailing Address - Country:US
Mailing Address - Phone:949-748-0710
Mailing Address - Fax:
Practice Address - Street 1:3261 S. BIG LAKE RD. STE D3-D4
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:AK
Practice Address - Zip Code:99652
Practice Address - Country:US
Practice Address - Phone:907-892-5669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental