Provider Demographics
NPI:1669886651
Name:OLSON FAMILY DENTAL, PLLC
Entity type:Organization
Organization Name:OLSON FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-852-4933
Mailing Address - Street 1:3725 CROSSING STREET SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701
Mailing Address - Country:US
Mailing Address - Phone:701-852-4933
Mailing Address - Fax:
Practice Address - Street 1:3725 CROSSING STREET SW
Practice Address - Street 2:SUITE B
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701
Practice Address - Country:US
Practice Address - Phone:701-852-4933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40712Medicaid