Provider Demographics
NPI:1285453670
Name:CARLSON, NOLAN RYAN
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:RYAN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 60TH ST SE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548
Mailing Address - Country:US
Mailing Address - Phone:616-483-0750
Mailing Address - Fax:
Practice Address - Street 1:280 60TH ST SE
Practice Address - Street 2:SUITE #200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548
Practice Address - Country:US
Practice Address - Phone:616-483-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902018221124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist