Healthcare Provider Details

I. General information

NPI: 1518889179
Provider Name (Legal Business Name): JACK ROBERT OLSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 USS JAMES MADISON RD
KINGS BAY GA
31547
US

IV. Provider business mailing address

3113 W MIRAMAR CIR
SIOUX FALLS SD
57108-1507
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-4212
  • Fax:
Mailing address:
  • Phone: 605-951-7667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS-10497
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: