Provider Demographics
NPI:1871646588
Name:OLSON, MARK GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GREGORY
Last Name:OLSON
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 1:10645 SAINT CROIX TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-6775
Mailing Address - Country:US
Mailing Address - Phone:651-674-1874
Mailing Address - Fax:
Practice Address - Street 1:13961 60TH ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-1053
Practice Address - Country:US
Practice Address - Phone:651-209-6312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8373122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist