Provider Demographics
NPI:1144540568
Name:OLSON, THOMAS OBERT (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:OBERT
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 1:250 FAME AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1587
Mailing Address - Country:US
Mailing Address - Phone:717-637-0202
Mailing Address - Fax:717-637-5855
Practice Address - Street 1:250 FAME AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1587
Practice Address - Country:US
Practice Address - Phone:717-637-0202
Practice Address - Fax:717-637-5855
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0382901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024778140001Medicaid