Healthcare Provider Details

I. General information

NPI: 1740514751
Provider Name (Legal Business Name): DR. LUKE D CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3617 W ARROWHEAD RD
DULUTH MN
55811-4046
US

IV. Provider business mailing address

3617 W ARROWHEAD RD
DULUTH MN
55811-4046
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-4484
  • Fax: 218-722-5217
Mailing address:
  • Phone: 218-722-4484
  • Fax: 218-722-5217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6357-15
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD12454
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: