Provider Demographics
NPI:1114165164
Name:CARLSON, DALLAS JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:DALLAS
Middle Name:JOHN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:DALLAS
Other - Middle Name:J
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:P.O. BOX 380
Mailing Address - Street 2:
Mailing Address - City:CAVALIER
Mailing Address - State:ND
Mailing Address - Zip Code:58220-0380
Mailing Address - Country:US
Mailing Address - Phone:701-265-6260
Mailing Address - Fax:701-265-8752
Practice Address - Street 1:301 MOUNTAIN STREET EAST
Practice Address - Street 2:
Practice Address - City:CAVALIER
Practice Address - State:ND
Practice Address - Zip Code:58220-0380
Practice Address - Country:US
Practice Address - Phone:701-265-6260
Practice Address - Fax:701-265-8752
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND279225100000X
SD522225100000X
MN1456225100000X
MT237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist