Provider Demographics
NPI:1417045048
Name:CARLSON, DUSTIN PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:PAUL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3221
Mailing Address - Country:US
Mailing Address - Phone:651-762-8040
Mailing Address - Fax:651-762-8070
Practice Address - Street 1:4717 CLARK AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3221
Practice Address - Country:US
Practice Address - Phone:651-762-8040
Practice Address - Fax:651-762-8070
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN599S5CAOtherBLUE CROSS IPN
MN614970700Medicaid
MN94027OtherHEALTHPARTNERS PIN
MN94027OtherHEALTHPARTNERS PIN
MN599S5CAOtherBLUE CROSS IPN
MN270057691OtherTAX ID NUMBER