Organization
INNOVATIVE DENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GRANT B OLSON DDS (PRESIDENT/OWNER)
(417) 889-4746
Entity
Organization
Contact information
Practice address
3424 S CULPEPPER CT, SPRINGFIELD, MO 65804-3755
(417) 889-4746
Mailing address
3424 S CULPEPPER CT, SPRINGFIELD, MO 65804-3755
(417) 889-4746
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
2011016216
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3424
DENTAL OFFICE
—
Enumeration date
05/21/2014
Last updated
05/21/2014
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