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General NPI Number Information
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NPI Number | 1841989647
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Entity Type | Individual
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Provider Name | TYLER MICHAEL OLSON
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Gender | Male
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Dates
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Enumeration Date | 05/05/2023
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 345 GARFIELD ST
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City | LANDER
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State | WY
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Zip | 82520-3123
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Country | US
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Telephone | 307-332-5297
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 PARK AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63104-3024
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Country | US
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Telephone | 314-833-2700
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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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 | 1676
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License Number State | WY
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