Healthcare Provider Details

I. General information

NPI: 1861553117
Provider Name (Legal Business Name): GREGORY D OLSEN DDS MSD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S HIGGINS AVE
MISSOULA MT
59801
US

IV. Provider business mailing address

1221 S HIGGINS AVE
MISSOULA MT
59801
US

V. Phone/Fax

Practice location:
  • Phone: 406-542-7572
  • Fax: 406-542-7713
Mailing address:
  • Phone: 406-542-7572
  • Fax: 406-542-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2134
License Number StateMT

VIII. Authorized Official

Name: DR. GREGORY DAVID OLSEN
Title or Position: PRESIDENT
Credential: DDS MSD
Phone: 406-542-7572