Provider Demographics
NPI:1043388259
Name:CARLSON, RICHARD D (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11362 SAN JOSE BLVD
Mailing Address - Street 2:STE 7
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7960
Mailing Address - Country:US
Mailing Address - Phone:904-262-8409
Mailing Address - Fax:904-262-4012
Practice Address - Street 1:11362 SAN JOSE BLVD
Practice Address - Street 2:STE 7
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7960
Practice Address - Country:US
Practice Address - Phone:904-262-8409
Practice Address - Fax:904-262-4012
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice