Provider Demographics
NPI:1477112068
Name:CARLSON, ADRIAN BRADLEY
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:BRADLEY
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6658 AIRPORT HWY
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-8135
Mailing Address - Country:US
Mailing Address - Phone:419-742-0396
Mailing Address - Fax:
Practice Address - Street 1:6658 AIRPORT HWY
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-8135
Practice Address - Country:US
Practice Address - Phone:419-742-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025850122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist