MEDICARE: BRIAN RAY OLESON D.D.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	122300000X	Dentist	5463	WA

General Provider Information

NPI Number	:	1518389733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN RAY OLESON D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 817
Second Line	:
City	:	HOODSPORT
State	:	WA
Zip	:	98548-0817
Country	:	US
Telephone Number	:	360-877-5151
Fax Number	:	360-877-5134

Provider Business Practice Location Address
First Line	:	N. 68 CUSHMAN AVE.
Second Line	:
City	:	HOODSPORT
State	:	WA
Zip	:	98548-0817
Country	:	US
Telephone Number	:	360-877-5151
Fax Number	:	360-877-5134

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

Provider Enumeration Date	:	01/07/2014
Last Update Date	:	01/07/2014

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