Healthcare Provider Details

I. General information

NPI: 1134377732
Provider Name (Legal Business Name): GEORGE R CARSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N MEADE AVE
GLENDIVE MT
59330-1631
US

IV. Provider business mailing address

116 N MEADE AVE
GLENDIVE MT
59330-1631
US

V. Phone/Fax

Practice location:
  • Phone: 406-377-8265
  • Fax:
Mailing address:
  • Phone: 406-377-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1321
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5510958
Identifier TypeOTHER
Identifier StateMT
Identifier IssuerCHIP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: