Provider Demographics
NPI:1063554434
Name:OLSEN, PHILLIP PETER (DMD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PETER
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E 500 S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-3882
Mailing Address - Country:US
Mailing Address - Phone:801-292-4141
Mailing Address - Fax:
Practice Address - Street 1:625 E 500 S
Practice Address - Street 2:SUITE 202
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-3882
Practice Address - Country:US
Practice Address - Phone:801-292-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6552335-8903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist