Provider Demographics
NPI:1013078955
Name:SMITH & OLSEN DENTAL LLC
Entity Type:Organization
Organization Name:SMITH & OLSEN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-837-7842
Mailing Address - Street 1:100 WILBURN RD
Mailing Address - Street 2:212
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1478
Mailing Address - Country:US
Mailing Address - Phone:608-837-7842
Mailing Address - Fax:608-837-0469
Practice Address - Street 1:100 WILBURN RD
Practice Address - Street 2:212
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1478
Practice Address - Country:US
Practice Address - Phone:608-837-7842
Practice Address - Fax:608-837-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55010151223G0001X
WI50017991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty