Provider Demographics
NPI:1598011561
Name:CARSON FAMILY DENTISTRY, PROF LLC
Entity Type:Organization
Organization Name:CARSON FAMILY DENTISTRY, PROF LLC
Other - Org Name:CARSON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CL;ARENCE
Authorized Official - Middle Name:NOLAN
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-369-2226
Mailing Address - Street 1:707 CHESTNUT ST
Mailing Address - Street 2:BOX 567
Mailing Address - City:SPRINGFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57062
Mailing Address - Country:US
Mailing Address - Phone:605-369-2226
Mailing Address - Fax:
Practice Address - Street 1:707 CHESTNUT ST
Practice Address - Street 2:BOX 567
Practice Address - City:SPRINGFIELD
Practice Address - State:SD
Practice Address - Zip Code:57062
Practice Address - Country:US
Practice Address - Phone:605-369-2226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM894261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1528154234Medicaid