Provider Demographics
NPI:1962997379
Name:DAHL, CARSON (DDS)
Entity type:Individual
Prefix:DR
First Name:CARSON
Middle Name:
Last Name:DAHL
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 1:322 OLD WIRE RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-9503
Mailing Address - Country:US
Mailing Address - Phone:317-488-0345
Mailing Address - Fax:
Practice Address - Street 1:702 N TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3324
Practice Address - Country:US
Practice Address - Phone:318-255-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist