Basic Information
Provider Information
NPI: 1952412975
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARLSON
FirstName: JAMES
MiddleName: WILLIAM
NamePrefix: DR.
NameSuffix: SR.
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1028 HAMPSTEAD RD
Address2:  
City: ESSEXVILLE
State: MI
PostalCode: 487321908
CountryCode: US
TelephoneNumber: 9894503160
FaxNumber:  
Practice Location
Address1: 1500 WEISS ST
Address2:  
City: SAGINAW
State: MI
PostalCode: 486025251
CountryCode: US
TelephoneNumber: 9894972500
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/31/2006
LastUpdateDate: 02/07/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X2901010647MIY Dental ProvidersDentist 

No ID Information.


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