Provider Demographics
NPI:1922041730
Name:OLSON, MITCHELL B (DDS PA)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:B
Last Name:OLSON
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 LYNDALE AVE S
Mailing Address - Street 2:STE E
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420
Mailing Address - Country:US
Mailing Address - Phone:952-884-1308
Mailing Address - Fax:952-884-3445
Practice Address - Street 1:8400 LYNDALE AVE S
Practice Address - Street 2:STE E
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:952-884-1308
Practice Address - Fax:952-884-3445
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice