Provider Demographics
NPI:1700495140
Name:SCOTT D CARLSON
Entity Type:Organization
Organization Name:SCOTT D CARLSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GERALYN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:BERENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-447-6054
Mailing Address - Street 1:4667 DAKOTA ST SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1714
Mailing Address - Country:US
Mailing Address - Phone:952-447-6054
Mailing Address - Fax:952-447-6139
Practice Address - Street 1:4667 DAKOTA ST SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1714
Practice Address - Country:US
Practice Address - Phone:952-447-6054
Practice Address - Fax:952-447-6139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental