Provider Demographics
NPI:1780816652
Name:OLSEN, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:12192 EVELY PINES LN
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669
Mailing Address - Country:US
Mailing Address - Phone:208-910-9000
Mailing Address - Fax:
Practice Address - Street 1:12192 EVELY PINES LN
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669
Practice Address - Country:US
Practice Address - Phone:208-910-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7371240-99211223G0001X
IDD-5015-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice