Provider Demographics
NPI:1598243990
Name:CARLSON DISTINCTIVE DENTISTRY, PLLC
Entity Type:Organization
Organization Name:CARLSON DISTINCTIVE DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-472-4713
Mailing Address - Street 1:6332 PARIS AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6828
Mailing Address - Country:US
Mailing Address - Phone:651-472-4713
Mailing Address - Fax:
Practice Address - Street 1:1701 CURVE CREST BLVD W STE 100
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-8840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6847-15OtherWI DENTAL BOARD
MND12115OtherMN BOARD OF DENTISTRY
1306976279OtherNPI
1306976279OtherNPI