Provider Demographics
NPI:1316224363
Name:CARLSON, PAUL MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MICHAEL
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 1:236 TANAGER PATH
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6394
Mailing Address - Country:US
Mailing Address - Phone:319-471-3466
Mailing Address - Fax:
Practice Address - Street 1:507 SOUTH SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187
Practice Address - Country:US
Practice Address - Phone:507-372-2072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND130101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice