Provider Demographics
NPI:1295821312
Name:CARLSON, KENNETH O (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:O
Last Name:CARLSON
Suffix:
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 1:2228 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732
Mailing Address - Country:US
Mailing Address - Phone:563-242-3104
Mailing Address - Fax:563-242-3482
Practice Address - Street 1:2228 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732
Practice Address - Country:US
Practice Address - Phone:563-242-3104
Practice Address - Fax:563-242-3482
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA5556122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0109942Medicaid