Provider Demographics
NPI:1588070866
Name:CARLSON, BRIEANNA LISE
Entity type:Individual
Prefix:
First Name:BRIEANNA LISE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 CARLSON PKWY
Mailing Address - Street 2:APT 316
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5337
Mailing Address - Country:US
Mailing Address - Phone:651-491-3550
Mailing Address - Fax:
Practice Address - Street 1:360 CARLSON PKWY
Practice Address - Street 2:APT 316
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5337
Practice Address - Country:US
Practice Address - Phone:651-491-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist