Provider Demographics
NPI:1669722823
Name:OLSON, BREANNA ROSE (RDH)
Entity type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:ROSE
Last Name:OLSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15188 N 75TH AVE
Mailing Address - Street 2:#280
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4723
Mailing Address - Country:US
Mailing Address - Phone:480-730-1857
Mailing Address - Fax:
Practice Address - Street 1:15188 N 75TH AVE
Practice Address - Street 2:#280
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4723
Practice Address - Country:US
Practice Address - Phone:480-730-1857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7347124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist