Provider Demographics
NPI:1265867691
Name:CARLSON DENTAL GROUP PROVIDERS, LLC
Entity Type:Organization
Organization Name:CARLSON DENTAL GROUP PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-262-8409
Mailing Address - Street 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:BLDG 1700
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-262-8409
Mailing Address - Fax:904-262-4012
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:BLDG 1700
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-262-8409
Practice Address - Fax:904-262-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN190241223G0001X
FLDN202751223G0001X
FLDN185321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty