Provider Demographics
NPI:1558566687
Name:CARLSON, MARY K (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:KANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2005 STOVER ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1544
Mailing Address - Country:US
Mailing Address - Phone:970-556-3026
Mailing Address - Fax:
Practice Address - Street 1:1840 FOLSOM ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5712
Practice Address - Country:US
Practice Address - Phone:303-443-5133
Practice Address - Fax:303-447-1752
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1054201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice