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General NPI Number Information
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NPI Number | 1013078955
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Entity Type | Organization
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Legal Business Name | SMITH & OLSEN DENTAL LLC
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 100 WILBURN RD 212
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City | SUN PRAIRIE
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State | WI
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Zip | 53590-1478
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Country | US
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Telephone | 608-837-7842
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Fax | 608-837-0469
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Provider Business Mailing Address
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Address Line | 100 WILBURN RD 212
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City | SUN PRAIRIE
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State | WI
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Zip | 53590-1478
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Country | US
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Telephone | 608-837-7842
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Fax | 608-837-0469
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARK D OLSEN
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Credential | DDS
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Telephone | 608-837-7842
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5001799
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5501015
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License Number State | WI
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