=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396188330
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNETTE RUSH OLSON D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2013
-----------------------------------------------------
Last Update Date | 04/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 E BAILEY BOSWELL RD SUITE 100
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76131-3569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-234-9378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 E BAILEY BOSWELL RD SUITE 100
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76131-3569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-234-9378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 18094
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------