Provider Demographics
NPI:1790014777
Name:OLSON DENTAL LLC
Entity Type:Organization
Organization Name:OLSON DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-447-4463
Mailing Address - Street 1:15870 FRANKLIN TRL SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2092
Mailing Address - Country:US
Mailing Address - Phone:952-447-4463
Mailing Address - Fax:
Practice Address - Street 1:15870 FRANKLIN TRL SE
Practice Address - Street 2:SUITE 200
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2092
Practice Address - Country:US
Practice Address - Phone:952-447-4463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty