Provider Demographics
NPI:1851505804
Name:OLESON, MARTIN H (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:H
Last Name:OLESON
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 1:210 S THIRD AVE
Mailing Address - Street 2:PO BOX 559
Mailing Address - City:CLEAR LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57226-0559
Mailing Address - Country:US
Mailing Address - Phone:605-874-2230
Mailing Address - Fax:605-874-2675
Practice Address - Street 1:210 S THIRD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:SD
Practice Address - Zip Code:57226-0559
Practice Address - Country:US
Practice Address - Phone:605-874-2230
Practice Address - Fax:605-874-2675
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM-5171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7802770Medicaid