Provider Demographics
NPI:1144527359
Name:OLSEN, GREGORY D (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18493 E WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4232 E CHANDLER BLVD STE 10
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-8879
Practice Address - Country:US
Practice Address - Phone:480-759-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0097821223X0400X
NVS3-259C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics