Provider Demographics
NPI:1417059478
Name:CARLSON, JAN RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:RAY
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JAN
Other - Middle Name:RAY
Other - Last Name:SHIRLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:133 E FAIRMOUNT AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1950
Mailing Address - Country:US
Mailing Address - Phone:716-763-0130
Mailing Address - Fax:
Practice Address - Street 1:133 E FAIRMOUNT AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1950
Practice Address - Country:US
Practice Address - Phone:716-763-0130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0582461223P0221X
KS603451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry