Provider Demographics
NPI:1124683818
Name:OLSON, SAMUEL IVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:IVAN
Last Name:OLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22249 HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:CO
Mailing Address - Zip Code:80642-9207
Mailing Address - Country:US
Mailing Address - Phone:303-886-2969
Mailing Address - Fax:
Practice Address - Street 1:11550 SHERIDAN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80020-3312
Practice Address - Country:US
Practice Address - Phone:720-464-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.002040291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty