Provider Demographics
NPI:1801283387
Name:CARLSON DENTAL GROUP RIVERSIDE, PA
Entity type:Organization
Organization Name:CARLSON DENTAL GROUP RIVERSIDE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-262-8409
Mailing Address - Street 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:BLDG 1700
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-262-8409
Mailing Address - Fax:904-262-4012
Practice Address - Street 1:501 RIVERSIDE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4934
Practice Address - Country:US
Practice Address - Phone:904-262-8409
Practice Address - Fax:904-262-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10002122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10002OtherDENTAL LICENSE NUMBER