Provider Demographics
NPI:1255340386
Name:CARLSON, FRED PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:PAUL
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 1:206 S BROADWAY STE 700
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6510
Mailing Address - Country:US
Mailing Address - Phone:507-289-8707
Mailing Address - Fax:
Practice Address - Street 1:206 S BROADWAY STE 700
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6510
Practice Address - Country:US
Practice Address - Phone:507-289-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8982122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist