MEDICARE: DR. RICHARD STANLEY OLESEN 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	122300000X	Dentist	D23549	CA

General Provider Information

NPI Number	:	1639360555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD STANLEY OLESEN DDS

Provider Business Mailing Address
First Line	:	2430 WEBSTER STREET
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705
Country	:	US
Telephone Number	:	510-843-4550
Fax Number	:	510-843-4553

Provider Business Practice Location Address
First Line	:	2430 WEBSTER STREET
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705
Country	:	US
Telephone Number	:	510-843-4550
Fax Number	:	510-843-4553

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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