Provider Demographics
NPI:1992831747
Name:CARLSTROM, MICHAEL DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:CARLSTROM
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 1:1049 E. LINCOLN HWY.
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1988
Mailing Address - Country:US
Mailing Address - Phone:815-485-7200
Mailing Address - Fax:
Practice Address - Street 1:1049 E. LINCOLN HWY.
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1988
Practice Address - Country:US
Practice Address - Phone:815-485-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice