Provider Demographics
NPI:1881665206
Name:CARLSON, KERRY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:S
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3225
Mailing Address - Country:US
Mailing Address - Phone:479-754-2042
Mailing Address - Fax:479-754-2429
Practice Address - Street 1:1619 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3225
Practice Address - Country:US
Practice Address - Phone:479-754-2042
Practice Address - Fax:479-754-2429
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS65831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice