Provider Demographics
NPI:1184880809
Name:OLSEN, EDWIN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:JOSEPH
Last Name:OLSEN
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 1:151 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HARDWICK
Mailing Address - State:VT
Mailing Address - Zip Code:05843-0537
Mailing Address - Country:US
Mailing Address - Phone:802-472-2260
Mailing Address - Fax:802-472-2263
Practice Address - Street 1:151 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:HARDWICK
Practice Address - State:VT
Practice Address - Zip Code:05843-0537
Practice Address - Country:US
Practice Address - Phone:802-472-2260
Practice Address - Fax:802-472-2263
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600006411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001913Medicaid