Provider Demographics
NPI:1528154234
Name:CARSON, CLARENCE NOLAN III (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:NOLAN
Last Name:CARSON
Suffix:III
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 1:707 CHESTNUT ST
Mailing Address - Street 2:PO BOX 567
Mailing Address - City:SPRINGFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57062
Mailing Address - Country:US
Mailing Address - Phone:605-369-2226
Mailing Address - Fax:
Practice Address - Street 1:707 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:SD
Practice Address - Zip Code:57062
Practice Address - Country:US
Practice Address - Phone:605-369-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM894122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46046213100Medicaid