Healthcare Provider Details

I. General information

NPI: 1184936403
Provider Name (Legal Business Name): OLSEN & OLSEN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10564 S US HIGHWAY 15 501 SUITE D
SOUTHERN PINES NC
28387-5167
US

IV. Provider business mailing address

10564 S US HIGHWAY 15 501 SUITE D
SOUTHERN PINES NC
28387-5167
US

V. Phone/Fax

Practice location:
  • Phone: 910-246-3232
  • Fax:
Mailing address:
  • Phone: 910-246-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8178
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8177
License Number StateNC

VIII. Authorized Official

Name: DR. JUSTIN T OLSEN
Title or Position: CO-MANAGER
Credential: DDS, MS
Phone: 910-246-3232