Provider Demographics
NPI:1730587007
Name:OLSON, SUSAN (DMD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 S. BIG LAKE RD. STE D3-D4
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652
Mailing Address - Country:US
Mailing Address - Phone:907-892-5669
Mailing Address - Fax:
Practice Address - Street 1:3896 N MARTIN L KING BLVD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-6603
Practice Address - Country:US
Practice Address - Phone:702-614-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist