MEDICARE: DONNA B OLSEN DDA AND RICHARD A OLSEN DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122400000X	Denturist	5941	NC
2	122400000X	Denturist	5940	NC

General Provider Information

NPI Number	:	1558357293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONNA B OLSEN DDA AND RICHARD A OLSEN DDS PA

Provider Business Mailing Address
First Line	:	8401 MEDICAL PLAZA DR
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-8797
Country	:	US
Telephone Number	:	704-593-1090
Fax Number	:	704-593-1092

Provider Business Practice Location Address
First Line	:	8401 MEDICAL PLAZA DR
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-8797
Country	:	US
Telephone Number	:	704-593-1090
Fax Number	:	704-593-1092

Authorized Official
Title or Position	:	OWNER PRESIDENT DENTIST
Name	:	DR. DONNA BARBAGLIA OLSEN
Credential	:	DMD
Telephone Number	:	704-593-1090

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	08/22/2020

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