Provider Demographics
NPI:1801105937
Name:WEST END DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:WEST END DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,FICD,FACD
Authorized Official - Phone:409-860-9600
Mailing Address - Street 1:6830 PHELAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-5970
Mailing Address - Country:US
Mailing Address - Phone:409-860-9600
Mailing Address - Fax:409-860-1704
Practice Address - Street 1:6830 PHELAN BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5970
Practice Address - Country:US
Practice Address - Phone:409-860-9600
Practice Address - Fax:409-860-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215191223G0001X
TX85531223G0001X
TX101541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty