Provider Demographics
NPI:1942348230
Name:CARLSON, MARVIN M (DDS)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:CARLTEN
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1558 WEATHERSTONE LN
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2019
Mailing Address - Country:US
Mailing Address - Phone:847-742-7886
Mailing Address - Fax:
Practice Address - Street 1:1558 WEATHERSTONE LN
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2019
Practice Address - Country:US
Practice Address - Phone:847-742-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice