Provider Demographics
NPI:1063404366
Name:CARLSON, BRYAN K (DMD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:K
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3501
Mailing Address - Country:US
Mailing Address - Phone:928-757-3223
Mailing Address - Fax:
Practice Address - Street 1:988 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3501
Practice Address - Country:US
Practice Address - Phone:928-757-3223
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD2794122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist