MEDICARE: SUSAN OLSON D.M.D

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	6555	NV

General Provider Information

NPI Number	:	1730587007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN OLSON D.M.D

Provider Business Mailing Address
First Line	:	3261 S. BIG LAKE RD. STE D3-D4
Second Line	:
City	:	BIG LAKE
State	:	AK
Zip	:	99652
Country	:	US
Telephone Number	:	907-892-5669
Fax Number	:

Provider Business Practice Location Address
First Line	:	3896 N MARTIN L KING BLVD
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-6603
Country	:	US
Telephone Number	:	702-614-1792
Fax Number	:

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

Provider Enumeration Date	:	12/18/2014
Last Update Date	:	02/06/2019

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