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General NPI Number Information
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NPI Number | 1194095778
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Entity Type | Individual
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Provider Name | MATTHEW ALLEN OLSON DMD
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Gender | Male
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Dates
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Enumeration Date | 01/12/2012
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Last Update Date | 01/12/2012
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Provider Practice Location Address
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Address Line | 715 11TH ST N STE 106B
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City | MOORHEAD
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State | MN
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Zip | 56560-2000
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Country | US
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Telephone | 218-299-7830
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Fax | 218-299-7832
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Provider Business Mailing Address
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Address Line | 374 5TH ST N APT 203
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City | FARGO
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State | ND
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Zip | 58102-4848
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Country | US
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Telephone | 503-869-3996
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | D13041
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License Number State | MN
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