Provider Demographics
NPI:1417140294
Name:OLSON, SCOTT M (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:OLSON
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 1:1722 S GLENSTONE AVE
Mailing Address - Street 2:SUITE GG
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1513
Mailing Address - Country:US
Mailing Address - Phone:417-823-4900
Mailing Address - Fax:417-823-8333
Practice Address - Street 1:1722 S GLENSTONE AVE
Practice Address - Street 2:SUITE GG
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1513
Practice Address - Country:US
Practice Address - Phone:417-823-4900
Practice Address - Fax:417-823-8333
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0160061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice