Healthcare Provider Details

I. General information

NPI: 1285453670
Provider Name (Legal Business Name): NOLAN RYAN CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 60TH ST SE SUITE #200
GRAND RAPIDS MI
49548
US

IV. Provider business mailing address

280 60TH ST SE SUITE #200
GRAND RAPIDS MI
49548
US

V. Phone/Fax

Practice location:
  • Phone: 616-483-0750
  • Fax:
Mailing address:
  • Phone: 616-483-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902018221
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: