Provider Demographics
NPI:1306931720
Name:CARLSON, TIMOTHY JON (DDS)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JON
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 1:657 ATLANTIC AVE.
Mailing Address - Street 2:HANCOCK DENTAL CLILNIC, P.A.
Mailing Address - City:HANCOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56244
Mailing Address - Country:US
Mailing Address - Phone:320-392-5300
Mailing Address - Fax:320-392-5302
Practice Address - Street 1:657 ATLANTIC AVE
Practice Address - Street 2:HANCOCK DENTAL CLILNIC, P.A
Practice Address - City:HANCOCK
Practice Address - State:MN
Practice Address - Zip Code:56244
Practice Address - Country:US
Practice Address - Phone:320-392-5300
Practice Address - Fax:320-392-5302
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND102121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice