Provider Demographics
NPI:1477587459
Name:DENNIS L CARLSON FAMILY DENTISTRY LTD
Entity Type:Organization
Organization Name:DENNIS L CARLSON FAMILY DENTISTRY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-741-0089
Mailing Address - Street 1:302 W CHESTNUT ST
Mailing Address - Street 2:200 TINI SQUARE BLDG
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2541
Mailing Address - Country:US
Mailing Address - Phone:218-741-0089
Mailing Address - Fax:
Practice Address - Street 1:302 W CHESTNUT ST
Practice Address - Street 2:200 TINI SQUARE BLDG
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2541
Practice Address - Country:US
Practice Address - Phone:218-741-0089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND77911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty