Active NPI
Mark Olsen, D.D.S.
- Pediatric Dentistry
- Star, ID
National Provider Identifier
1780816652
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- D-5015-PD
- Practice address
- 12192 Evely Pines LN
Star, ID 83669 - Phone
- (208) 910-9000
- NPI assigned
- Aug 11, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 7371240-9921 | UT | |
| Pediatric Dentistry | 1223P0221X | D-5015-PD | ID | Primary |
Addresses
Primary practice location
12192 Evely Pines LN
Star, ID 83669
Mailing address
12192 Evely Pines LN
Star, ID 83669
Phone (208) 910-9000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7371240-9921 | UT | MD | General Practice Dentistry |
| D-5015-PD | ID | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mark R Olsen DDS PLLC | Pediatric Dentistry | Current | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Pediatric Dentistry
- Nampa, ID
- NPI 1215712666
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1249948800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1582156800000",
"number": "1780816652",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12192 EVELY PINES LN",
"city": "STAR",
"state": "ID",
"postal_code": "83669",
"telephone_number": "208-910-9000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12192 EVELY PINES LN",
"city": "STAR",
"state": "ID",
"postal_code": "83669",
"telephone_number": "208-910-9000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "OLSEN",
"first_name": "MARK",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-08-11",
"last_updated": "2020-02-20",
"certification_date": "2020-02-20",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "UT",
"license": "7371240-9921",
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "ID",
"license": "D-5015-PD",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Star, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.