Provider Demographics
NPI:1679662696
Name:OLSON, DALE VICTOR (DDS)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:VICTOR
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 1:710 19TH AVE N
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1359
Mailing Address - Country:US
Mailing Address - Phone:651-451-1873
Mailing Address - Fax:651-451-8010
Practice Address - Street 1:710 19TH AVE N
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-1359
Practice Address - Country:US
Practice Address - Phone:651-451-1873
Practice Address - Fax:651-451-8010
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26723OLOtherBCBS
MNT39784Medicare UPIN