Provider Demographics
NPI:1164697066
Name:CARLSON, RUSSELL EDGAR III (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:EDGAR
Last Name:CARLSON
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 66TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50311-1705
Mailing Address - Country:US
Mailing Address - Phone:515-279-0856
Mailing Address - Fax:515-255-6907
Practice Address - Street 1:1145 66TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50311-1705
Practice Address - Country:US
Practice Address - Phone:515-279-0856
Practice Address - Fax:515-255-6907
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA65351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA500058Medicaid