Basic Information
| Provider Information | |||||||||
| NPI: | 1609855774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GRANT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1811 ARMY BLVD | ||||||||
| Address2: | USA DENTAC FT. SAM HOUSTON | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782342686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102210826 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1811 ARMY BLVD | ||||||||
| Address2: | USA DENTAC FT. SAM HOUSTON | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782342686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102210826 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 4940888-9922 | UT | N | Dental Providers | Dentist | 1223E0200X | 4940888-9922 | UT | Y | Dental Providers | Dentist | Endodontics |
No ID Information.