Provider Demographics
NPI:1184912263
Name:OLSON, BROCK L (DMD)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:L
Last Name:OLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 N 8TH ST W
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3318
Mailing Address - Country:US
Mailing Address - Phone:307-856-9725
Mailing Address - Fax:307-856-7075
Practice Address - Street 1:621 N 8TH ST W
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3318
Practice Address - Country:US
Practice Address - Phone:307-856-9725
Practice Address - Fax:307-856-7075
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice