Provider Demographics
NPI:1063425130
Name:CARLSON, FREDRICK D (DDS)
Entity type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:D
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 1:717 S STATE ST
Mailing Address - Street 2:STE 700
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:507-238-1883
Mailing Address - Fax:507-238-1612
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:STE 700
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-238-1883
Practice Address - Fax:507-238-1612
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6851122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist