Provider Demographics
NPI:1639287535
Name:CARLSON, DAVID CHARLES (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHARLES
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:C
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:111 MAIN
Mailing Address - City:TIOGA
Mailing Address - State:ND
Mailing Address - Zip Code:58852-0758
Mailing Address - Country:US
Mailing Address - Phone:701-664-2582
Mailing Address - Fax:701-664-2581
Practice Address - Street 1:111 MAIN STREET
Practice Address - Street 2:
Practice Address - City:TIOGA
Practice Address - State:ND
Practice Address - Zip Code:58852
Practice Address - Country:US
Practice Address - Phone:701-664-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist