Provider Demographics
NPI:1023239803
Name:CARLSON, DALE GARY (LAC)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:GARY
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 E WILDS RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85739-9679
Mailing Address - Country:US
Mailing Address - Phone:520-825-8999
Mailing Address - Fax:
Practice Address - Street 1:39580 S LAGO DEL ORO PKWY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85739-1091
Practice Address - Country:US
Practice Address - Phone:520-624-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ090455163W00000X
AZ410171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered171100000XOther Service ProvidersAcupuncturist