Provider Demographics
NPI:1336214386
Name:OLSON, KEITH ALAN (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
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 1:1317 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265
Mailing Address - Country:US
Mailing Address - Phone:320-269-6416
Mailing Address - Fax:320-269-8136
Practice Address - Street 1:1317 GROVE AVE
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265
Practice Address - Country:US
Practice Address - Phone:320-269-6416
Practice Address - Fax:320-269-8136
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist