1336302249 NPI number — DR. JUSTIN T OLSEN DDS

Table of content: DR. JUSTIN T OLSEN DDS (NPI 1336302249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336302249 NPI number — DR. JUSTIN T OLSEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSEN
Provider First Name:
JUSTIN
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336302249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 N. STONEWALL AVE
Provider Second Line Business Mailing Address:
PO BOX 26901
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73190-3044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 N. STONEWALL AVE
Provider Second Line Business Practice Location Address:
POST OFFICE BOX 26901
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73190-3044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-271-4148
Provider Business Practice Location Address Fax Number:
405-271-6012
Provider Enumeration Date:
07/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  8178 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)