MEDICARE: DR. ALEXIS B OLSSON DDS

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)		IL

General Provider Information

NPI Number	:	1598753212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXIS B OLSSON DDS

Provider Business Mailing Address
First Line	:	201 E HURON ST
Second Line	:	12-100
City	:	CHICAGO
State	:	IL
Zip	:	60611-3197
Country	:	US
Telephone Number	:	312-926-6333
Fax Number	:	312-926-3444

Provider Business Practice Location Address
First Line	:	201 E HURON ST
Second Line	:	12-100
City	:	CHICAGO
State	:	IL
Zip	:	60611-3197
Country	:	US
Telephone Number	:	312-926-6333
Fax Number	:	312-926-3444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	07/08/2007

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