Provider Demographics
NPI:1184637258
Name:CARLSON DENTAL OFFICE PA
Entity Type:Organization
Organization Name:CARLSON DENTAL OFFICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-238-1883
Mailing Address - Street 1:717 S STATE ST
Mailing Address - Street 2:STE 700
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:507-238-1883
Mailing Address - Fax:507-238-1612
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:STE 700
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-238-1883
Practice Address - Fax:507-238-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6851122300000X
MN11032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty