Provider Demographics
NPI:1720203466
Name:CARLSON, PHILIP L JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:L
Last Name:CARLSON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:37 PEARL ST
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743
Mailing Address - Country:US
Mailing Address - Phone:814-642-2661
Mailing Address - Fax:814-642-9388
Practice Address - Street 1:37 PEARL ST
Practice Address - Street 2:
Practice Address - City:PORT ALLEGANY
Practice Address - State:PA
Practice Address - Zip Code:16743
Practice Address - Country:US
Practice Address - Phone:814-642-2661
Practice Address - Fax:814-642-9388
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018186L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist