Provider Demographics
NPI:1053351791
Name:OLSSON, TINA M (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:OLSSON
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:DR
Other - First Name:TINA
Other - Middle Name:MOANA-MARIE
Other - Last Name:OBRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:412 BOWES DR
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466
Mailing Address - Country:US
Mailing Address - Phone:253-752-5511
Mailing Address - Fax:253-752-4442
Practice Address - Street 1:412 BOWES DR
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466
Practice Address - Country:US
Practice Address - Phone:253-752-5511
Practice Address - Fax:253-752-4442
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000111631223E0200X, 122300000X
WADEN000111631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223E0200XDental ProvidersDentistEndodontics