Healthcare Provider Details

I. General information

NPI: 1417334764
Provider Name (Legal Business Name): JOHN D OLSSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9013 KEY PENINSULA HWY N
LAKEBAY WA
98349-8518
US

IV. Provider business mailing address

9013 KEY PENINSULA HWY N
LAKEBAY WA
98349-8518
US

V. Phone/Fax

Practice location:
  • Phone: 253-884-9455
  • Fax: 253-884-9466
Mailing address:
  • Phone: 253-884-9455
  • Fax: 253-884-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5464
License Number StateWA

VIII. Authorized Official

Name: DR. JOHN D OLSSON
Title or Position: OWNER
Credential: DDS
Phone: 253-884-9455