Provider Demographics
NPI:1366835019
Name:DR. DANIEL W. CARLSON D.D.S., DENTISTRY INC.
Entity Type:Organization
Organization Name:DR. DANIEL W. CARLSON D.D.S., DENTISTRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF DENTAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELW
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-697-6212
Mailing Address - Street 1:22089 471ST AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-7139
Mailing Address - Country:US
Mailing Address - Phone:605-695-3117
Mailing Address - Fax:
Practice Address - Street 1:102 22ND AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2654
Practice Address - Country:US
Practice Address - Phone:605-697-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM4091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty