Provider Demographics
NPI:1922851716
Name:OLSON, CLARKE HARRY (LD)
Entity Type:Individual
Prefix:
First Name:CLARKE
Middle Name:HARRY
Last Name:OLSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-2955
Mailing Address - Country:US
Mailing Address - Phone:406-245-4884
Mailing Address - Fax:
Practice Address - Street 1:1826 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-2955
Practice Address - Country:US
Practice Address - Phone:406-245-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DTR-LIC-28043122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist