Provider Demographics
NPI:1285653071
Name:OLSON, BRANT N (DDS,PA)
Entity type:Individual
Prefix:
First Name:BRANT
Middle Name:N
Last Name:OLSON
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S SKYLINE DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3292
Mailing Address - Country:US
Mailing Address - Phone:208-522-9101
Mailing Address - Fax:208-522-2517
Practice Address - Street 1:250 S SKYLINE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3292
Practice Address - Country:US
Practice Address - Phone:208-522-9101
Practice Address - Fax:208-522-2517
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD33861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice