Provider Demographics
NPI:1639197809
Name:OLSON, JAMES RANDALL (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDALL
Last Name:OLSON
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 1:986 S MAIN
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937
Mailing Address - Country:US
Mailing Address - Phone:928-536-7741
Mailing Address - Fax:928-536-7741
Practice Address - Street 1:986 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5500
Practice Address - Country:US
Practice Address - Phone:928-536-5353
Practice Address - Fax:928-536-5353
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist