Provider Demographics
NPI:1891158143
Name:CARLSON, BRIAN (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CARLSON
Suffix:
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 1:1060 MCKINLEY MALL
Mailing Address - Street 2:
Mailing Address - City:BLASDELL
Mailing Address - State:NY
Mailing Address - Zip Code:14219-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 MCKINLEY MALL
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219
Practice Address - Country:US
Practice Address - Phone:716-954-8705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040995122300000X
390200000X
NY060288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program