Provider Demographics
NPI:1700934122
Name:OLSEN, MARY LOUISE (RDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:OLSEN
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 1:5565 COUNTY ROAD 34 NW
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-9702
Mailing Address - Country:US
Mailing Address - Phone:320-491-4052
Mailing Address - Fax:
Practice Address - Street 1:700 CEDAR ST
Practice Address - Street 2:#44
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1769
Practice Address - Country:US
Practice Address - Phone:320-491-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH6003124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist