Healthcare Provider Details

I. General information

NPI: 1659579043
Provider Name (Legal Business Name): ROSS G OLNESS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 1ST ST S SKYLARK CENTER
WILLMAR MN
56201-4243
US

IV. Provider business mailing address

1280 WEST LAWRENCE RD
CLOQUET MN
55720
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-1739
  • Fax:
Mailing address:
  • Phone: 651-983-9113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12383
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: