Provider Demographics
NPI:1952418618
Name:CARLSON, MARK TAGUE (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TAGUE
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 1:2041 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5147
Mailing Address - Country:US
Mailing Address - Phone:336-777-0303
Mailing Address - Fax:336-777-3448
Practice Address - Street 1:1400 WALTER REED RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4409
Practice Address - Country:US
Practice Address - Phone:910-864-9884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
9026XOtherBLUE CROSS BLUE SHIELD NC
NC5903721Medicaid
1587738OtherUNITED CONCORDIA