Provider Demographics
NPI:1932248606
Name:CARLSON, SUSAN L (RDH, BS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 36TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4323
Mailing Address - Country:US
Mailing Address - Phone:206-325-4763
Mailing Address - Fax:
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:SUITE 1240
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1720
Practice Address - Country:US
Practice Address - Phone:206-325-4763
Practice Address - Fax:206-325-4763
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00001002124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist