Provider Demographics
NPI:1568433563
Name:CARLSON, CARRIE (DDS)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 JOHNSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-2108
Mailing Address - Country:US
Mailing Address - Phone:320-629-2282
Mailing Address - Fax:
Practice Address - Street 1:505 JOHNSON AVE SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-2108
Practice Address - Country:US
Practice Address - Phone:320-629-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN328608800Medicaid