Provider Demographics
NPI:1740465244
Name:OLSEN BROTHERS DENTAL P.L.L.C.
Entity type:Organization
Organization Name:OLSEN BROTHERS DENTAL P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-491-9911
Mailing Address - Street 1:1840 E BASELINE RD
Mailing Address - Street 2:STE A-2
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1527
Mailing Address - Country:US
Mailing Address - Phone:480-491-9911
Mailing Address - Fax:480-491-9921
Practice Address - Street 1:1840 E BASELINE RD
Practice Address - Street 2:STE A-2
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1527
Practice Address - Country:US
Practice Address - Phone:480-491-9911
Practice Address - Fax:480-491-9921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72301223G0001X
AZ73901223G0001X
AZ73931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty