Provider Demographics
NPI:1760716773
Name:CARLSON, KIRSTIN M
Entity Type:Individual
Prefix:DR
First Name:KIRSTIN
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4046
Mailing Address - Country:US
Mailing Address - Phone:218-722-4484
Mailing Address - Fax:218-722-5217
Practice Address - Street 1:3617 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4046
Practice Address - Country:US
Practice Address - Phone:218-722-4484
Practice Address - Fax:218-722-5217
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6356-151223X0400X
MND124871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics