Provider Demographics
NPI:1407858517
Name:PALMBLAD, CARL PETER (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:PETER
Last Name:PALMBLAD
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 1:14 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2116
Mailing Address - Country:US
Mailing Address - Phone:631-473-0052
Mailing Address - Fax:631-474-9066
Practice Address - Street 1:14 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2116
Practice Address - Country:US
Practice Address - Phone:631-473-0052
Practice Address - Fax:631-474-9066
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NY0411841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01043241Medicaid
NYBP1207112OtherDEA