Provider Demographics
NPI:1851400766
Name:OLSON, MICHELLE LEA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEA
Last Name:OLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 SOUTHMOOR DR UNIT 305
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-3771
Mailing Address - Country:US
Mailing Address - Phone:757-355-4948
Mailing Address - Fax:
Practice Address - Street 1:4939 COURTHOUSE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2687
Practice Address - Country:US
Practice Address - Phone:757-259-0741
Practice Address - Fax:757-259-0718
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122561223G0001X
VA04014129831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice