Provider Demographics
NPI:1881822104
Name:CARLSON, PETER LOREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LOREN
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 1:17032 WOODVINE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-7911
Mailing Address - Country:US
Mailing Address - Phone:405-509-0361
Mailing Address - Fax:
Practice Address - Street 1:1201 N STONEWALL AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-4441
Practice Address - Fax:405-271-1134
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery