Provider Demographics
NPI:1376609412
Name:CARLSON, GARY LEROY (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEROY
Last Name:CARLSON
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Gender:M
Credentials:DDS, MSD
Other - Prefix:
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Mailing Address - Street 1:17809 HUTCHINS DR
Mailing Address - Street 2:STE 101
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4100
Mailing Address - Country:US
Mailing Address - Phone:952-474-3203
Mailing Address - Fax:952-474-3204
Practice Address - Street 1:17809 HUTCHINS DR
Practice Address - Street 2:STE 101
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4100
Practice Address - Country:US
Practice Address - Phone:952-474-3203
Practice Address - Fax:952-474-3204
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MND68521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics