Provider Demographics
NPI:1730233412
Name:OLSEN, GEORGE MARTIN (DDS)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:MARTIN
Last Name:OLSEN
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 1:237 SW HIGGINS AVE
Mailing Address - Street 2:STE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1403
Mailing Address - Country:US
Mailing Address - Phone:406-721-2830
Mailing Address - Fax:406-549-5053
Practice Address - Street 1:237 SW HIGGINS AVE
Practice Address - Street 2:STE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1403
Practice Address - Country:US
Practice Address - Phone:406-721-2830
Practice Address - Fax:406-549-5053
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT110162Medicaid
MT5511480OtherCHIP