Provider Demographics
NPI:1790725844
Name:CARLSON, JOHN TERRY (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TERRY
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 HELEN KELLER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-2983
Mailing Address - Country:US
Mailing Address - Phone:205-556-2323
Mailing Address - Fax:205-556-2341
Practice Address - Street 1:651 HELEN KELLER BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-2983
Practice Address - Country:US
Practice Address - Phone:205-556-2323
Practice Address - Fax:205-556-2341
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL37451223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000090515Medicaid
ALT86062Medicare UPIN
AL000090515Medicare ID - Type Unspecified