Provider Demographics
NPI:1053490250
Name:CARLSON, HOWARD RICHARD (DDS PS)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:RICHARD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DDS PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:PATEROS
Mailing Address - State:WA
Mailing Address - Zip Code:98846-0518
Mailing Address - Country:US
Mailing Address - Phone:509-923-2250
Mailing Address - Fax:
Practice Address - Street 1:145 LAKE SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:PATEROS
Practice Address - State:WA
Practice Address - Zip Code:98846-0518
Practice Address - Country:US
Practice Address - Phone:509-923-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5898122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5075403Medicare ID - Type Unspecified