Healthcare Provider Details

I. General information

NPI: 1184207839
Provider Name (Legal Business Name): MICHAEL JOHN OLMSTEAD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INDIAN HILLS COMMUNITY COLLEGE 525 GRANDVIEW AVE.
OTTUMWA IA
52501-0000
US

IV. Provider business mailing address

1752 MAHARISHI CENTER AVE BUILDING C UNIT 3
FAIRFIELD IA
52556
US

V. Phone/Fax

Practice location:
  • Phone: 641-683-5111
  • Fax:
Mailing address:
  • Phone: 808-639-9422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberFAC-40186
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberFAC-40186
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: