MEDICARE: DR. DOUGLAS PETER OLSON D.M.D., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	056560	NY
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	D8888	OR

General Provider Information

NPI Number	:	1144369125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS PETER OLSON D.M.D., M.S.

Provider Business Mailing Address
First Line	:	1100 MAIN ST
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14209-2308
Country	:	US
Telephone Number	:	716-242-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	KADENA AB
Second Line	:	UNIT 5270
City	:	APO
State	:	AP
Zip	:	96367
Country	:	US
Telephone Number	:	315-630-4902
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/07/2014

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