Healthcare Provider Details

I. General information

NPI: 1558357863
Provider Name (Legal Business Name): GARY B OLSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 8TH ST S SUITE 202
WISCONSIN RAPIDS WI
54494-6511
US

IV. Provider business mailing address

3930 8TH ST S SUITE 202
WISCONSIN RAPIDS WI
54494-6511
US

V. Phone/Fax

Practice location:
  • Phone: 715-421-3366
  • Fax: 715-421-3353
Mailing address:
  • Phone: 715-421-3366
  • Fax: 715-421-3353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1723G
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: