Provider Demographics
NPI:1437533643
Name:CARLSON, JASON J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:J
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2262
Mailing Address - Country:US
Mailing Address - Phone:815-397-4280
Mailing Address - Fax:815-484-2436
Practice Address - Street 1:1301 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2262
Practice Address - Country:US
Practice Address - Phone:815-397-4280
Practice Address - Fax:815-484-2436
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist