Provider Demographics
NPI:1144369125
Name:OLSON, DOUGLAS PETER (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:PETER
Last Name:OLSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2308
Mailing Address - Country:US
Mailing Address - Phone:716-242-8200
Mailing Address - Fax:
Practice Address - Street 1:KADENA AB
Practice Address - Street 2:UNIT 5270
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96367
Practice Address - Country:US
Practice Address - Phone:315-630-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0565601223X0400X
ORD88881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics