Healthcare Provider Details

I. General information

NPI: 1124952536
Provider Name (Legal Business Name): JACK KYLE CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 UNIVERSITY DR S
FARGO ND
58103-6049
US

IV. Provider business mailing address

3115 UNIVERSITY DR S
FARGO ND
58103-6049
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-8884
  • Fax: 701-232-8884
Mailing address:
  • Phone: 701-232-8884
  • Fax: 701-232-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2588
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: